PSR Director's update for April 2025

A. Director or Associate Director’s section 92 agreements effective in April 2025

Three agreements entered into by the Director or an Associate Director and persons under review (under section 92 of the Act) came into effect in April 2025:

General practitioner

During the review period, the practitioner rendered or initiated the following Medicare Benefits Schedule (MBS) items in excess of 99% of their peers:

• 23 (professional attendance – less than 20 minutes)
• 66596 (iron studies)
• 66833 (vitamin D quantification)
• 66839 (quantification of vitamin B12 markers)

 The Director reviewed this practitioner’s provision of MBS items:

• 23
• 721 (preparation of a GP management plan)
• 5020 (after-hours attendance – less than 20 minutes)
• 66596
• 66833
• 91891 (phone attendance – at least 6 minutes).

The Director had persisting concerns that:

• the MBS requirements, including the requirements for MBS items 23, 5020 and 91891 to take an adequate patient history and examination, were not always met
• the practitioner billed level B attendances (being MBS items 23, 5020 and 91891) in circumstances that peers would consider straightforward
• the practitioner initiated pathology services as part of a battery of tests, including where the clinical relevance was unclear
• the practitioner’s record keeping was inadequate, including where their clinical notes did not contain sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering or initiating MBS item 23, 721, 5020, 66596, 66833 and 91891 services. The practitioner agreed to repay $450,000, to be disqualified from providing MBS item 721 and 92024 (video attendance to a prepare a GP management plan) services for 9 months, and will be counselled by the Director. 

Plastic surgeon

During the review period, the practitioner rendered 86 different MBS items in excess of 99% of their peers, including:

• 104 (specialist attendance – first attendance)
• 105 (specialist attendance – subsequent attendance)
• 111 (specialist attendance – including an unscheduled operation)
• 18266 (injection of an anaesthetic agent to the ulnar, radial or median nerve)
• 30023 (debridement of traumatic or deep soft tissue wound)
• 30196 (removal of malignant neoplasm of skin or mucus membrane)
• 39330 (neurolysis by open operation without transposition)
• 45201 (muscle, myocutaneous or skin flap to repair a surgical excision made in the removal of a skin lesion)
• 45206 (single stage local flap to repair a defect on eyelid, nose, lip, ear, neck, hand, thumb, finger or genitals)
• 45500 (microvascular repair using microsurgical techniques, with restoration of continuity of artery or vein of distal extremity or digit)
• 45563 (neurovascular island flap for restoration of essential sensation in the digits or sole of the foot, or for genital reconstruction).

The Director reviewed this practitioner’s rendering of MBS item 104, 111, 30023, 30196, 39330, 45201, 45206, 45500 and 45563 services. The Director had no persisting concerns in relation to MBS items 104, 45500 and 45563 services. In relation to the remaining items, the Director had persisting concerns that:

• the MBS requirements were not always met for attendance and therapeutic items
• therapeutic procedures rendered by the practitioner were not always clinically indicated or justified, including when these items were co-billed
• the practitioner’s record keeping was inadequate, including where there were no consultation notes for some reviewed services.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 111, 30023, 30196, 39330, 45201 and 45206. The practitioner agreed to repay $141,500, to be disqualified from providing MBS item 30196 services for 12 months and will be counselled by the Director.

General practitioner

During the review period, the practitioner rendered the following MBS items in excess of 99% of their peers:

• 36 (professional attendance – at least 20 minutes)
• 44 (professional attendance – at least 40 minutes)
• 721

An Associate Director reviewed this practitioner’s rendering of MBS item 36, 44, 721, 723 (development of team care arrangements (TCAs)) and 732 (review of a GPMP or TCA) services. 

The Associate Director had persisting concerns that: 

• the MBS requirements, including minimum time requirements where relevant, were not always met 
• the practitioner did not always provide adequate clinical input and management
• the practitioner initiated pathology services where the clinical indication was unclear
• the practitioner’s record keeping was inadequate, including where their documentation did not contain sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 36, 44, 721, 723 and 732 services. The practitioner agreed to repay $260,000, to be disqualified from providing MBS item 721, 723, 732, 92024, 92025 (video attendance to develop a TCA), and 92028 (video attendance to review a GPMP or TCA) services for 12 months, and will be reprimanded and counselled by the Associate Director.

B. No further action decisions

There were no decisions to take no further action in April 2025.

C. PSR Committee final determinations

PSR Committee 1512

On 7 April 2025 a final determination came into effect regarding a chiropractor. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS item 10964 (chiropractic health service – at least 20 minutes), 57712 (diagnostic imaging – hip joint), 57715 (diagnostic imaging – pelvic girdle) and 58112 (diagnostic imaging – 2 spine examinations) services during the review period. Many of the reviewed services were provided by chiropractors employed or otherwise engaged by the practitioner’s company. However, some of the services were also provided by the practitioner personally.

The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $340,000. This reflects approximately 80% of the benefits paid for the MBS item 10964, 57712, 57715 and 58112 services in connection with which they were found to have engaged in inappropriate practice
• be disqualified from providing MBS item 10964, 57712, 57715 and 58112 services for a period of 6 months.

In relation to the MBS item 10964 services the Committee made findings based on one or more of the following:

• As an officer of a body corporate, the practitioner recklessly or negligently permitted another practitioner employed by the body corporate to engage in inappropriate practice, by: 
  • failing to provide sufficient clinical input into the service
  • providing a service that did not the requirements of the MBS item descriptor
  • failing to keep an adequate record of the service
  • using the practitioner’s provider number to bill for the service
  • using the practitioner’s requester number to request a diagnostic imaging service that was initiated by the associate practitioner
• The MBS requirements were not met, including that the service would not have lasted at least 20 minutes
• The clinical input into the service was inadequate
• The clinical record was otherwise inadequate.

In relation to the MBS item 57712, 57715 and 58112 services the Committee made findings based on one or more of the following:

• As an officer of a body corporate, the practitioner recklessly or negligently permitted another practitioner employed by the body corporate to engage in inappropriate practice, by: 
  • failing to provide sufficient clinical input into the service
  • failing to keep an adequate record of the service
  • using the practitioner’s requester number to request a diagnostic imaging service that was initiated by the associate practitioner. 
• The MBS requirements were not met, including that there was sometimes no need for a report by a radiologist.
• The clinical input into the service was inadequate, including in relation to obtaining informed patient consent.
• The service was not clinically indicated. In relation to MBS item 57715, there was not always clinical indication for initiating an x-ray of the pelvic girdle, including in female patients of reproductive age.
• The clinical record was inadequate, including when there was no record for the date of service.
• The arrangement entered into between the practitioner’s company and a radiology company unacceptably incentivised the request for a service that was not necessary for the treatment of the patient and/or created a situation where the patient was not given adequate choice about which provider to use.

PSR Committee 1526

On 7 April 2025 a final determination came into effect regarding a chiropractor. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS item 10964, 57712, 57715 and 58112 services during the review period. Some of the reviewed services were provided by chiropractors employed or otherwise engaged by the practitioner’s company. However, many services were provided by the practitioner personally.

The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $325,000. This reflects approximately 75% of the benefits paid for the MBS item 10964, 57712, 57715 and 58112 services in connection with which they were found to have engaged in inappropriate practice
• be disqualified from providing MBS item 10964, 57712, 57715 and 58112 services for 6 months.

In relation to the MBS item 10964 services the Committee made findings based on one or more of the following:

• As an officer of a body corporate, the practitioner recklessly or negligently permitted another practitioner employed by the body corporate to engage in inappropriate practice, by: 
  • providing a service that did not the requirements of the MBS item descriptor
  • failing to keep an adequate record of the service
  • using the practitioner’s provider number to bill for the service.
• The MBS requirements were not met, including that the service would not have lasted at least 20 minutes, and the practitioner did not provide a written report back to the referring practitioner.
• The service was not clinically indicated.
• The practitioner’s clinical input into the service was inadequate.
• The clinical record was inadequate, including when there was no record for the service.

In relation to the MBS item 57712, 57715 and 58112 services the Committee made findings based on one or more of the following:

• As an officer of a body corporate, the practitioner recklessly or negligently permitted another practitioner employed by the body corporate to engage in inappropriate practice, by: 
  • failing to provide sufficient clinical input into the service
  • rendering or initiating a service that was not clinically indicated
  • failing to keep an adequate record of the service 
  • using the practitioner’s requester number to request a diagnostic imaging service that was initiated by the associate practitioner. 
• The practitioner’s clinical input into the service was inadequate.
• The MBS requirements were not met, including that there was sometimes no need for a report by a radiologist.
• The service was not clinically indicated, including in female patients of reproductive age.
• The clinical record was inadequate, including when there was no record for the date of service.
• The arrangement entered into between the practitioner’s company and a radiology company unacceptably incentivised the request for a service that was not necessary for the treatment of the patient.

PSR Committee 1567

On 10 April 2025 a final determination came into effect regarding a general practitioner. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS item 5028 (after-hours attendance at a residential aged care facility – less than 20 minutes) and 90035 (attendance at a residential aged care facility – less than 20 minutes) services during the review period.

The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $100,000. This reflects approximately the total benefits paid for the MBS item 5028 and 90035 services in connection with which the practitioner was found to have engaged in inappropriate practice
• be disqualified from rendering MBS item 5028, 90035 and 91891 services for 12 months.

In relation to the MBS item 5028 services the Committee made findings based on one or more of the following:

• the practitioner’s clinical input into the service was inadequate or insufficient, including in relation to the management plan for the patient
• the medical record was inadequate, including where it was unclear, misleading, or not realistically capable of being relied upon by another practitioner assuming patient care.

In relation to the MBS item 90035 services the Committee made findings based on one or more of the following:

• the practitioner’s clinical input into the service was inadequate or insufficient, including in relation to taking a history and implementing a management plan for the patient
• the medical record was inadequate, including where it was unclear, misleading or not realistically capable of being relied upon by another practitioner assuming patient care
• the patient was not eligible for an MBS item 90035 service, although this would not on its own support a finding of inappropriate practice.

PSR Committee 1584

On 10 April 2025 a final determination came into effect in relation to a general practitioner. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with the following MBS and PBS services during the review period:

• 23
• 721
• 723
• 732
• 2700 (attendance to prepare a GP mental health treatment plan (GPMHTP) – 20 to 40 minutes)
• 5000 (after-hours attendance – for a straightforward problem)
• 5020
• 31357 (excision of non-malignant skin lesion – less than 6mm in diameter)
• 31360 (excision of non-malignant skin lesion – at least 6mm in diameter)
• 31362 (excision of non-malignant skin lesion – less than 14mm in diameter)
• 31364 (excision of non-malignant skin lesion – at least 14mm in diameter)
• 91809 (phone attendance – less than 20 minutes)
• 2089Y (temazepam 10 mg tablet, 25)
• 2335X (pregabalin 75 mg capsule, 56)
• 3162K (diazepam 5 mg tablet, 50), and
• 8455B (tramadol hydrochloride 50 mg capsule, 20).

The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $350,000. This reflects approximately 65% of the benefits paid for the MBS item 23, 721, 723, 732, 2700, 5000, 5020, 31362, 91809, 31357, 31360 and 31364 services in connection with which the practitioner was found to have engaged in inappropriate practice
• have their Part VII authority to prescribe or supply pharmaceuticals under the PBS suspended for 24 months,
• be fully disqualified from rendering MBS item services for 24 months.

In relation to the MBS item 23 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that there was insufficient clinical content to justify a Level B consultation, or the patient did not attend on the date of service.
• The practitioner’s clinical input into the service was inadequate, including that patient consent to a procedure was not obtained.
• The medical record was inadequate.

In relation to the MBS item 721 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that the GPMP was not a comprehensive plan to manage the patient’s chronic conditions, the patient was not eligible for the service, and/or the GPMP was not sufficiently individualised to the patient’s condition.
• The practitioner did not provide sufficient clinical input into the service.
• The medical record was otherwise inadequate.

In relation to MBS item 723 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including where the patient was not eligible for the service, the TCA document was not sufficiently individualised to the patient and/or there was no evidence of collaboration with 2 other providers
• The practitioner’s clinical input into the service was insufficient.
• The medical record was otherwise inadequate.

In relation to MBS item 732 services the Committee made findings based on one or more of the following:

• the MBS requirements were not met, including that deficiencies in relation to the GPMP were not rectified upon review, the practitioner did not collaborate with at least 2 other health care providers when reviewing TCAs and/or the practitioner did not record the patient’s consent to the service.
• The practitioner’s clinical input into the service was inadequate, including that they did not undertake a meaningful review of the patient’s GPMP or TCA.
• The medical record was otherwise inadequate. 

In relation to MBS item 2700 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including where the practitioner did not attend the patient on the date of service, no GPMHTP was prepared on the date of service, or there was insufficient clinical input recorded to justify a consultation lasting at least 20 minutes.
• The GPMHTP did not reflect that the practitioner sufficiently assessed the patient’s mental health needs, agreed goals and actions with the patient, or provided or referred the patient for appropriate treatment and services.
• The practitioner’s clinical input into the service was insufficient.
• The medical record was otherwise inadequate.

In relation to MBS item 5000 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that the practitioner did not provide a service to the patient on the relevant date.
• The medical record was otherwise inadequate.

In relation to MBS item 5020 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met
• The practitioner’s clinical input into the service was inadequate.
• The medical record was otherwise inadequate.

In relation to MBS item 31360 services the Committee made findings based on the medical record being inadequate.

In relation to MBS item 31362 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that MBS item 31362 did not apply to the type of lesion removed and/or there was no record for an excision undertaken on the date of service.
• The excision was not clinically indicated.
• The practitioner did not record patient consent to the procedure.
• The practitioner’s clinical input into the service was insufficient.
• The medical record was otherwise inadequate.

In relation to MBS item 31364 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including in relation to the size or nature of the lesion removed.
• The practitioner’s clinical input into the service was inadequate.
• The medical record was inadequate.

In relation to MBS item 91809 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that there was no record of a service being provided.
• The practitioner did not provide sufficient clinical input into the service.
• The medial record was otherwise inadequate.

In relation to the PBS item 2089Y, 2335X, 3162K and 8455B services the Committee made findings based on one or more of the following:

• The practitioner’s clinical input in the service was insufficient.
• The medical record was inadequate.
• Specifically in relation to PBS item 3162K, there was no documentation of an authority to prescribe the medication.

PSR Committee 1621

On 11 April 2025 a final determination came into effect in relation to a general practitioner. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS item 23, 721, 723, 732, 2713 (attendance in relation to a mental disorder – at least 20 minutes), 56223 (computed tomography – scan of lumbosacral spine), 56507 (computed tomography – scan of upper abdomen and pelvis) and 66596 services during the review period.

The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $537,000. This reflects approximately 100% of the Medicare benefits that were paid for the MBS item 23, 721, 723, 732 and 2713 services in connection with which the practitioner was found to have engaged in inappropriate practice
• be fully disqualified from rendering MBS item services for 3 months
• at the end of that period, be disqualified from rendering MBS item 721, 723, 732, 2713, 92024, 92025, 92028 and 92115 (video attendance in relation to a mental disorder – at least 20 minutes) services for an additional 12 months.

In relation to the MBS item 23 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met.
• The medical record was inadequate.
• The practitioner’s clinical input was insufficient or inadequate.
• The service was not clinically relevant.
• For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS item 23.

In relation to the MBS item 721 services the Committee made findings based on one or more of the following:

• the MBS requirements were not met, including that the practitioner used a standard GPMP template which was not adequately individualised to address the patient’s healthcare needs and did not identify management goals, actions to be taken by the patient or treatment and services the patient was likely to need.
• The GPMP was not a comprehensive document and would not assist the patient or their treating practitioner to manage their conditions.
• The medical record was otherwise inadequate.
• The GPMP was not clinically indicated.
• For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS item 721.

In relation to the MBS item 723 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that the TCAs did not involve collaboration with other providers, the TCA document was a standard template that did not reflect the specific treatment and service goals required for the patient, and the patient was not eligible for an MBS item 723 service.
• The medical record was otherwise inadequate.
• The service was not clinically indicated.
• For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS item 723.

In relation to MBS item 732 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that documentation was based on templates and not sufficiently individualised to the patient, the practitioner did not undertake sufficient review of the goals in the GPMP, and the practitioner did not review the input of collaborating providers under TCAs.
• The medical record was otherwise inadequate.
• The practitioner’s clinical input was inadequate.
• For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS item 732.

In relation to MBS item 2713 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that the service did not relate to a mental health disorder, the practitioner did not spend at least 20 minutes with the patient in relation to a mental health issue.
• The medical record was otherwise inadequate.
• The practitioner’s clinical management or clinical input was inadequate.
• For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS item 2713.

In relation to initiating MBS item 56223 and 56507 services the Committee made findings based on one or more of the following:

• A CT scan was not clinically indicated.
• The practitioner’s clinical input was inadequate.
• The medical record was inadequate.

In relation to initiating MBS item 66596 services the Committee made findings based on one or more of the following:

• The pathology studies ordered were not clinically indicated.
• The practitioner’s clinical management was inadequate.

PSR Committee 1635

On 10 April 2025 a final determination came into effect in relation to a general practitioner. In the final report of the PSR Committee, the practitioner was found to have engaged in inappropriate practice in connection with MBS item 23, 36, 5020 and 5040 (after-hours attendance – at least 20 minutes) services during the review period.

The practitioner was directed to:

• be reprimanded
• be counselled
• repay the amount of $250,000. This reflects approximately 75% of the benefits paid for the MBS item 23, 36, 5020 and 5040 services in connection with which the practitioner was found to have engaged in inappropriate practice
• be disqualified from rendering MBS item 36 and 5040 services for 6 months.

In relation to the MBS item 23 and 5020 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that the practitioner did not take a patient history, perform an examination or provide preventative healthcare advice where it would have been clinically relevant to do so.
• The service constituted routine aftercare, which should not have been billed as a separate service.
• The practitioner’s clinical input into the service was insufficient.
• The medical record was inadequate.

In relation to the MBS item 36 and 5040 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including where the practitioner did not take a comprehensive history or perform an examination when it would have been clinically relevant to do so, and where the record did not reflect sufficient clinical input to justify an attendance of at least 20 minutes.
• The practitioner did not provide sufficient clinical input into the service.
• The record was insufficient to support billing a separate attendance item in addition to a co-billed procedural item.
• The medical record was otherwise inadequate.

D. Federal Court

No final decisions concerning PSR were handed down in April 2025.

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

0 matters were referred to the major non-compliance (fraud) division in April 2025.

F. Referrals to AHPRA (106XA/B)

0 matters were referred to AHPRA in April 2025.