PSR Director's Update for May 2022

8 June 2022

 

 

Due to the nature of negotiated agreements and secrecy limitations imposed by the legislative scheme, no practitioners who have entered into s 92 agreements with the Director are named.  The Director has the power to disclose the names and addresses of practitioners who are found by a Committee to have engaged in inappropriate practice and who are subject to a final determination.  For media enquiries, please contact PSR at 02 6120 9100 or feedback@psr.gov.au.

Read the Director’s policy on the naming of practitioners in PSR’s Policy on the Publication of Case Outcomes

 

Five section 92 agreements and 2 final determinations came into effect in May.

A. Director’s Section 92 agreements effective in May 2022

Five agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in May 2022.

An agreement with a radiologist

During the review period, the practitioner billed Medicare Benefits Schedule (MBS) items 104, 18222, 55848, 57341 and 55850 in association in excess of their peers. The Director reviewed this practitioner’s rendering and initiating of MBS items 104, 18222, 55036, 55065, 55848, 55850, 57341 and 57703. The Director had persisting concerns that:

  • for MBS item 104, there was no evidence of a consultation service separate to the co-billed diagnostic imaging investigation and no separate consultation was clinically indicated
  • the MBS item 18222 requirements were not met as the procedure performed was an injection rather than an infusion
  • MBS item 18222 was inappropriately co-billed with items 55848, 55850 and 57341 in circumstances where the entirety of the service fell within the co-billed item
  • services were inappropriately split over multiple attendances where there was no clinical indication to do so, causing additional MBS items to be billed
  • the practitioner’s records for MBS item 104 services were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 104, 18222, 55065, 55848, 55850 and 57341. The practitioner agreed to repay $200,000, to be disqualified from providing MBS items 104, 18222, 91822 and 92832 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 91822 and 92832 reflects disqualification from equivalent telehealth items where applicable.

An agreement with an otolaryngologist

During the review period, the practitioner billed MBS items 11324, 41764 and 41707 in a volume in excess of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 105, 11324, 41683, 41764 and 41707. The Director had persisting concerns that:

  • the clinical input for some surgical procedures may not have been sufficient
  • component surgical MBS items were inappropriately co-billed when they were part of a larger surgical procedure billed to Medicare in circumstances where the entirety of the service fell within the MBS item for the larger procedure
  • billing of MBS item 11324 services were not always clinically indicated and where this item was co-billed with other services, the MBS requirements for each billed service were not always met
  • the practitioner’s records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 11324, 41683, 41707 and 41764. The practitioner agreed to repay $50,000 and will be reprimanded by the Director.

An agreement with an oral and maxillofacial surgeon

During the review period, the practitioner billed MBS items 30023, 41722, 45720, 45726 and 45735 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 18234, 30023, 41722, 45720, 45726 and 45735.  The Director had persisting concerns that:

  • the practitioner may not have performed or undertaken all required aspects of each of the procedures that were billed
  • MBS requirements were not always met, including in relation to MBS item 18234 that the injection was not into a primary division of the trigeminal nerve as required by the item descriptor
  • MBS item 30023 was billed in circumstances where it formed part of a broader co-billed surgical procedure
  • the technique for MBS items 18234 and 41722 did not meet the standard expected of peers
  • consent procedures and records were not always adequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing items 18234, 30023, 41722, 45720, 45726 and 45735. The practitioner agreed to repay $400,000, to be disqualified from providing MBS items 30023, 45720, 45726 and 45735 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 23, 193, 197, 721, and 723 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering and initiating of MBS items 23, 36, 197, 721, 723, 732, 2712, 2713, 2715, 66596, 66716, 66734, 66833, 66839, 69496 and 71164, and in Group I3 subgroups 1, 2 and 6 (relating to diagnostic imaging services). The Director had no persisting concerns in respect of the practitioners’ initiation of diagnostic imaging services. The Director had persisting concerns that:

  • the MBS descriptors were not always met, including minimum time requirements where relevant
  • there was insufficient clinical input into many services rendered
  • many pathology services were initiated as part of a standard broad spectrum testing panel, rather than being clinically indicated for the patient
  • the records for chronic disease management (CDM) services were over reliant on templates that were not individualised for the patient
  • the practitioner's records were otherwise inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 197, 721, 723, 732, 2712, 2713, 2715, 66596, 66716, 66734, 66833, 66839, 69496 and 71164. The practitioner agreed to repay $260,000, to be disqualified from providing MBS items 197, 2715 and 92117 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 92117 reflects disqualification from the equivalent telehealth item for MBS item 2717. 

An agreement with a general practitioner

During the review period, the practitioner rendered a total volume of services in excess of 97% of their peers and MBS items 721, 723 and 732 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 3, 23, 36, 160, 703, 721, 723, 732, 2521, 2713, 2715, 92072 and 92127 . The Director had persisting concerns that:

  • the practitioner inappropriately allowed their provider number to be used for services that the practitioner did not provide
  • the MBS requirements were not always met, including:
    • minimum time requirements where relevant
    • patients to whom MBS item 160 services were provided were not in imminent danger of death and were not attended on for at least an hour
  • patients were not always in attendance for MBS item 3 services
  • the practitioner’s clinical input was insufficient
  • the records for CDM services were over-reliant on templates that were not individualised for the patient
  • the practitioner’s records were otherwise inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 3, 23, 36, 160, 703, 721, 723, 732, 2521, 2713, 2715, 92072 and 92127. The practitioner agreed to repay $300,000, to be disqualified from providing MBS items 721, 723, 732, 2715, 92024, 92025, 92028, 92068, 92069, 92072 and 92116 services for 12 months, and will be reprimanded by the Director. The disqualification from MBS items 92024, 92025, 92028, 92068, 92069, 92072 and 92116 reflects disqualification from equivalent telehealth items where applicable.

B. PSR Committee final determinations

Two final determinations came into effect in May 2022.

PSRC 1310

On 3 May 2022 a final determination came into effect regarding a general practitioner. The practitioner was directed to:

  • be reprimanded
  • be counselled and
  • repay $216,256 to the Commonwealth.

These directions followed from a final report of a PSR Committee, which concluded that the practitioner had engaged in inappropriate practice in connection with services rendered as MBS items 36, 721, 723, 732, 2713, 11610 and 11611.

In relation to professional attendances items, MBS items 36, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the practitioner’s clinical input was inadequate
  • MBS item requirements were not met including that there was insufficient clinical content to justify an attendance of at least 20 minutes duration
  • the medical records were inadequate.

In relation to MBS items 721, 723 and 732, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • MBS item requirements were not met including that the practitioner did not attempt to consult with at least two collaborating providers for Team Care Arrangements (TCA), the TCA document was insufficient in clarifying which providers were to be consulted, and in GP Management Plan (GPMP) review services there was no review of the patient’s progress against goals in the GPMP.
  • the practitioner’s GPMP, TCA and review documents were inadequate and the practitioner’s clinical input into GPMP and review services was not sufficient
  • on some occasions, the GPMP was not created contemporaneous to a consultation, and lacked patient input.

In relation to MBS item 2713, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • MBS requirements were not met, including that there was insufficient clinical content to justify a consultation of a duration of at least 20 minutes
  • the medical record was inadequate including that the practitioner did not record any clinical content addressing the patient’s mental health.

In relation to MBS items 11610, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the service was billed, but in some cases it was not performed
  • where the service was performed:
    • the MBS requirements were not met
    • the service was not clinically indicated
    • the practitioner’s clinical input was inadequate, and/or the record was inadequate and misleading
  • the record was otherwise inadequate.

In relation to MBS items 11611, the Committee made findings of inappropriate practice on the basis that MBS requirements were not met.

PSRC 1323

On 3 May 2022 a final determination came into effect regarding Dr Johannes Bester, a general practitioner, who practised in Wyoming, New South Wales. The practitioner was directed to:

  • be reprimanded
  • be counselled
  • repay $672,273.46 to the Commonwealth and
  • be fully disqualified from rendering MBS item services for a period of 18 months.

These directions followed from a final report of a PSR Committee, which concluded that Dr Bester had engaged in inappropriate practice in connection with services rendered as MBS items 23, 36, 707, 721, 723, 732, 31361, 31362, 31363, 31364, 31368, 45200, 45617 and 66596.

In relation to professional attendances items, MBS items 23 and 36, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the medical records were inadequate
  • the MBS requirements were not met
  • the clinical input provided into the service was inadequate
  • for MBS item 23, services were rendered for the provision of standard after-care
  • for MBS item 36, there was insufficient clinical detail or input recorded to support the minimum attendance time of at least 20 minutes.

In relation to MBS item 707, the Committee made findings of inappropriate practice on the basis of one or more of the following reasons:

  • the patient was not in attendance for the service
  • the MBS requirements were not met, including that the assessment did not last at least 60 minutes, and two professional attendance items were billed across multiple days in relation to a single patient attendance
  • the medical records were inadequate
  • the clinical input provided into the service was inadequate.

In relation to CDM services, the Committee’s findings of inappropriate practice were widespread. In relation to MBS items 721, 723 and 732, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the patient was not in attendance for the service
  • Dr Bester’s pattern of billing had the effect of circumventing the prohibition on co-billing MBS item 23 and 36 services with a CDM item for the same professional attendance
  • the clinical input provided into the service was inadequate
  • the medical record was inadequate.

In relation to MBS item 721 services the Committee also made findings of inappropriate practice based on the MBS requirements not being met, including that the GP Management Plan was not a comprehensive plan for the management of the patient’s conditions, there was no baseline assessment of the patient’s conditions, and the goals were not individualised to allow assessment of progress over time.

In relation to MBS items 723 services the Committee also made findings of inappropriate practice based on the MBS requirements not being met, including that there was no collaboration with at least two other providers and no TCA was performed on the date of service.

In relation to MBS items 732 services the Committee also made findings of inappropriate practice based on there being no review on the date of service.

In relation to therapeutic procedure items, MBS items 31361, 31362, 31363, 31364, 31368, 45200 and 45617, the Committee made findings of inappropriate practice on the basis of one or more of the following:

  • the MBS requirements were not met, including by reference to the site or nature of the lesion
  • the co-billing of an MBS item 23 or 36 service was not appropriate
  • the medical record was inadequate.

In relation to MBS item 31362 and 31364 services the Committee also made findings of inappropriate practice based on one or more of the following that:

  • the service was not clinically indicated
  • the clinical input provided into the service was inadequate.

In relation to MBS item 31368 services, the Committee also made findings of inappropriate practice based on the patient to being in attendance and no lesion being removed.

In relation to MBS item 45200 and 45617 services, the Committee also made findings of inappropriate practice based on the MBS requirements not being met, including that these items were billed when a skin flap procedure or blepharoplasty service was not performed.

In relation to MBS item 66595, the Committee made findings of inappropriate practice on the basis that the clinical input provided into the service was inadequate and the medical record was inadequate.

C. Federal Court

No decision concerning PSR was handed down in May 2022.

D. Referrals to the major non-compliance (fraud) division (89A & 106N)

One matter was referred to the major non-compliance (fraud) division in May 2022.

E. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in May 2022.