PSR Director's update for July 2023

Published date

28 August 2023

A. Director’s Section 92 agreements effective in July 2023

19 agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect in July:

An agreement with a company

During the review period, practitioners employed or otherwise engaged by the company rendered Medicare Benefits Schedule (MBS) items disproportionately to peers. The Director reviewed the rendering by practitioners employed or otherwise engaged by the company and had persisting concerns that one or more of the practitioners:

failed to meet the MBS descriptor and regulatory requirements for all items rendered
billed attendance items where an attendance was not indicated and/or not performed by the practitioner, and
failed to keep an adequate and contemporaneous record

And that:

the practitioners were employed or otherwise engaged by the company either directly or indirectly,
were sufficiently controlled and supervised by the company such that the practitioners were knowingly, recklessly or negligently caused or permitted by the company to engage in such conduct

The company acknowledged having knowingly, recklessly or negligently caused or permitted practitioners employed or otherwise engaged by the company to engage in inappropriate practice. The company agreed to repay $1,160,000, provide employed or otherwise engaged practitioners with access to specified information, and be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 193, 197 and 199 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 193, 197 and 199. The Director had persisting concerns that:

MBS requirements were not always met. For example, it was not always clear that the practitioner examined patients and implemented management plans as required and/or that minimum time requirements had been met
the practitioner’s record keeping was inadequate. For example, progress notes were sometimes difficult to read or illegible and often included minimal history, examination or unique input, and
the practitioner’s clinical input was insufficient for some services, including where the practitioner’s practice model included seeing up to nine acupuncture patients concurrently.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 193, 197 and 199. The practitioner agreed to repay $360,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered or initiated MBS items 23, 699, 721, 723, 2199, 2713, 2715, 16591, 66719, 66833 and 66839 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering or initiation of MBS items 23, 36, 699, 707, 721, 723, 732, 2195, 2199, 2713, 2715, 5020, 16591, 66719, 66833 and 66839 services and had no persisting concerns in relation to MBS item 23. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met, including minimum time requirements where relevant
the practitioner did not provide sufficient clinical input into each service, including when providing chronic disease management (CDM) and mental health services and when co-billing multiple services
the practitioner provided or initiated pathology services that were not clinically indicated.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 36, 699, 707, 721, 723, 732, 2195, 2199, 2713, 2715, 5020, 16591, 66719, 66833 and 66839. The practitioner agreed to repay $124,000 and will be counselled by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered MBS items 23, 5020, 5040, 30071, 30192 and 31376 in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 5020, 5040, 30071, 30192, 30196, 30202, 31358, 31361, 31363, 31365, 31367, 31376 and 45201, and had no persisting concerns in relation to MBS items 23, 5020, 30071, 31358, 31361, 31363, 31365 and 31367. The Director had persisting concerns in relation to the remaining items that:

MBS requirements, including minimum time requirements where relevant, were not always met
not all therapeutic procedures were clinically indicated, including excisions that were larger than appeared to be necessary
the practitioner’s record keeping was inadequate. The practitioner’s records did not always include sufficient clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 5040, 30192, 30196, 30202, 31376 and 45201. The practitioner agreed to repay $40,000, to be disqualified from providing MBS item 31376 services for 24 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 707, 721, 723, 2713, 2715, 41692, 41716, 41786, 42644, 47354 and 47361 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 707, 721, 723, 732, 2713, 2715, 10990, 41500, 41672, 41692, 41716, 41737, 41752, 41764, 41786, 42644, 47354, 47361, 47405, 47423, 91809 and 91891, and had no persisting concerns in relation to MBS items 10990, 41500, 41672, 41692, 41716, 41737, 41752, 41764, 47354, 47405 and 47423. The Director had persisting concerns in relation to the remaining items that:

the practitioner’s record keeping was inadequate. For example, many of the reviewed records were heavily reliant on templates with little or no individualisation for the patient
MBS requirements, including minimum time requirements were not always met
the practitioner’s clinical input was inadequate. For example, the practitioner did not appear to always have clinical input into health assessments.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 707, 721, 723, 732, 2713, 2715, 41786, 42644, 47361, 91809 and 91891. The practitioner agreed to repay $700,000, to be disqualified from providing MBS item 707, 721, 723, 732, 2713, 2715, 92024, 92025, 92028, 92115, 92116, 92127 and 42644 services for 12 months, to be disqualified from providing MBS item 36, 91801 services for 6 months, to be disqualified from providing MBS item 91809 and 91891 services for 3 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered or initiated MBS items 721, 723, 2717, 2143, 2195, 66719, 66596, 92024, 92025, 92028 and 92069 in excess of 98% of their peers and prescribed Pharmaceutical Benefits Scheme (PBS) items 2662B, 3162K, 1215Y, 8254K, 2089Y and 2335X in excess of 98% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 2143, 2195, 2717, 10997, 66596, 66719, 92068 and 92069, and PBS items 1215Y, 2089Y, 2335X, 2622B, 3162K and 8254K, and had no persisting concerns in relation to MBS item 2195. The Director had persisting concerns in relation to the remaining items that:

MBS requirements, including minimum time requirements where relevant, were not met
Initiation of pathology services and prescribing were not always clinically indicated, or the practitioner’s records did not always reflect a clinical indication for services
the practitioner’s record keeping was inadequate. For example, the records did not always include adequate clinical information to explain the service.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering or initiating MBS Items 23, 36, 721, 723, 732, 2143, 2717, 10997, 66596, 66719, 92068 and 92069 and prescribing PBS Items 1215Y, 2089Y, 2335X, 2622B, 3162K and 8254K. The practitioner agreed to repay $361,200, to be disqualified from providing MBS item 721, 723, 732, 2143, 92024, 92025 and 92028 services for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered or initiated MBS items 721, 732, 92068, 92069, and 92072 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering or initiation of MBS items 23, 36, 703, 721, 723, 732, 10997, 66596, 66716, 66833, 91809, 92068, 92069 and 92072. The Director had persisting concerns that:

MBS requirements, including minimum time requirements where relevant, were not always met
the practitioner did not always provide the sufficient clinical input. For example, it was not always clear that the practitioner provided the service personally
the practitioner provided or initiated services which were not clinically indicated. The practitioner’s records did not always reflect a clinical indication for services.
the practitioner’s record keeping was inadequate. For example, the practitioner did not always include adequate clinical information to explain the service, and the records would not enable another practitioner to undertake the patient’s ongoing care.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering or initiating MBS Items 23, 36, 703, 721, 723, 732, 10997, 66596, 66716, 66833, 91809, 92068, 92069, and 92072. The practitioner agreed to repay $343,000, to be disqualified from providing MBS item 92024, 92025, 92028, 92068, 92069 and 92072 services for 12 months, and will be reprimanded and counselled by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered MBS items 44 and 91811 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 91809, 91810 and 91811. The Director had persisting concerns that:

MBS requirements were not met. For example, services were not always of sufficient complexity to justify billing Level B services.
the practitioner’s record keeping was inadequate. For example, records failed to include important clinical information.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 36, 44, 91809, 91810, and 91811. The practitioner agreed to repay $240,000, to be disqualified from providing MBS item 44 and 91802 services for 12 months, to be disqualified from providing MBS item 36 and 91801 services for 6 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, the practitioner rendered MBS item 23 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering or initiation of MBS items 23, 2712, 2717, 66596, 66719, 66833 and 66839. The Director had persisting concerns that:

MBS requirements were not met. For example, MBS item 2712 and 2717 services did not meet requirements for a general practitioner mental health plan
there was not always a clinical indication for services rendered or initiated. For example, pathology services were ordered for patients without any presenting symptoms to justify the service
the practitioner’s record keeping was inadequate. For example, records were brief, and did not always contain sufficient information to explain what occurred during the consultation.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering or initiating MBS Items 23, 2712, 2717, 66596, 66719, 66833, and 66839. The practitioner agreed to repay $220,000, to be disqualified from providing MBS item 2717 and 92117 services for 12 months, and will be reprimanded and counselled by the Director.

An agreement with a medical practitioner

During the review period, the practitioner rendered MBS item 54, 57, 5208 and 91813 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 54, 57, 279, 282, 5207, 5208, 11312, 11506, 11610, 11707, 91813, 91814 and 92133. The Director had persisting concerns that:

MBS requirements, including minimum time requirements where relevant, were not met
there was not always a clinical indication for services rendered or initiated , including the use of MBS diagnostic procedure items as screening tools
the practitioner’s clinical input was insufficient. For example, the practitioner failed to perform necessary examinations
the practitioner’s record keeping was inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 54, 57, 282, 5207, 5208, 91813, 92133, 11312, 11506 and 11797. The practitioner agreed to repay $246,000, to be disqualified from providing MBS item 57, 5208, 91805, 92121, 92123, 92133, 279 and 282 services for 6 months, to be disqualified from providing MBS item 54, 5207 and 91804 services for 3 months, and to be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS item 36, 721, 723, 91809 and 91810 services in excess of 99% of their peers. The Director reviewed this practitioner’s rendering or initiation of MBS items 23, 36, 721, 723, 5040, 55833, 56220, 56223, 56501, 66596, 66833, 91809, 91810, 92068, and 92069, and prescribing of PBS items 1215Y, 2089Y, 2622B, 3162K, 8501K, 8523N and 8525Q. The Director had no persisting concerns in relation to MBS items 55833, 56501, 91810, 92068 and 92069. The Director had persisting concerns in relation to the remaining items that

MBS requirements were not always met. For example it was not always clear that MBS 721 services involved a comprehensive plan for the management of a patient’s chronic disease
the practitioner’s records were inadequate. For example, records often included information which was duplicated from prior entries for the same or other patients without amendments to reflect the specific consultations.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 23, 36, 721, 723, 5040, 56220, 56223, 66596, 66833 and 91809, and prescribing PBS items 1215Y, 2089Y, 2622B, 3162K, 8501K, 8523N and 8525Q. The practitioner agreed to repay $778,500, to be disqualified from providing MBS item 36, 723, 721, 5040, 92024, 92025 and 91801 services for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered total services disproportionately to their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 707, 721, 723, 732, 5020, 10997 and 91809, and had no persisting concerns in relation to MBS items 732. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met. For example, it was not always clear that a patient history was taken for MBS item 23 services where it was clinically relevant.
the practitioner did not provide sufficient clinical input for some services including where the risks of prescribed medication were not discussed with the patient.
the practitioner’s records were inadequate. For example, the records were brief, and lacked sufficient information for another practitioner to undertake care of the patient

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 23, 707, 721, 723, 5020, 10997 and 91809. The practitioner agreed to repay $320,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 92024, 92025, 92028, 92068, 92069 and 92072 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 707, 721, 723, 732, 2525, 11707, 92024, 92025, 92028, 92068, 92069 and 92072, and had no concerns in relation to MBS item 23. The Director had persisting concerns in relation to the remaining items that:

MBS requirements, including minimum time requirements where relevant, were not always met
there was often no apparent clinical indication for MBS item 11610 and 11707 services
the practitioner did not provide sufficient clinical input for some services including where the service was provided by a nurse without involvement by the practitioner
the practitioner’s record keeping was inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 707, 721, 723, 732, 2525, 11707, 92024, 92025, 92028, 92069 and 92072. The practitioner agreed to repay $140,000, and will be reprimanded and counselled by the Director.

An agreement with an orthopaedic surgeon

During the review period, the practitioner rendered MBS items 49321, 49521 and 49524 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 104, 105, 49321, 49521 and 49524, and had no persisting concerns in relation to MBS items 104 and 105. The Director had persisting concerns that in relation to the procedural items that:

MBS requirements were not always met. For example, therapeutic procedures were not completed in the manner and form required
there was not always a clinical indication for services rendered by the practitioner.
the practitioner’s record keeping was inadequate . For example, there was insufficient detail included in operation reports

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS items 49321, 49521, and 49524. The practitioner agreed to repay $410,000, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered a prescribed pattern of MBS attendance services (the 80/20 rule) and prescribed PBS items 1215Y, 3162K, 2622B and 8386J in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS item 3 and PBS items 1215Y, 2622B, 3162K and 8386J, and provision of a prescribed pattern of services. The Director had no persisting concerns in relation to MBS items 3, and in relation to prescribed pattern of services the Director considered that exceptional circumstances existed that affected the rendering of services on each of the days constituting the prescribed pattern of services. The Director had persisting concerns in relation to the remaining items that:

the practitioner’s prescribing was not always within PBS restrictions or did not comply with PBS authority requirements
there was not always clinical indication for prescribing. For example, multiple centrally-acting medications were frequently co-prescribed without clear indication.
the practitioner’s record keeping was inadequate. For example, there was inadequate recording of advice concerning risks and side effects of medication. The practitioner acknowledged having engaged in inappropriate practice in connection with prescribing PBS Items 1215Y, 2622B, 3162K and 8386J. The practitioner agreed to be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 37, 47, 5049, 5067, 90043, 90051 and 91801 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 37, 44, 47, 705, 743, 5028, 5049, 5067, 90035, 90043, 90051, 91800, 91801, 91802 and 91810, and had no persisting concerns in relation to MBS items 37, 44, 5028, 5049, 5067, 91801 and 91802. The Director had persisting concerns in relation to the remaining items that:

MBS requirements, including minimum time requirements where relevant, were not met
there was not always sufficient clinical input provided in rendering services. For example, the practitioner did not always provide sufficient assessment or examination for MBS item 705 services
the practitioner’s record keeping was inadequate . For example, there was not always a progress note able to located for services rendered.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 47, 705, 743, 90035, 90043, 90051, 91800 and 91810. The practitioner agreed to repay $135,000, to be disqualified from providing MBS item 705 services for 12 months, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723, 2713 and 2715 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering or initiation of MBS items 36, 721, 723, 2713, 2715, 2717 and 66653. The Director had persisting concerns that:

MBS requirements were not always met. For example, there was not always evidence of a chronic disease for MBS item 721 and 723 services .
the practitioner’s record keeping was inadequate. For example, the consultation notes did not always contain sufficient clinical information to explain the services and sometimes lacked adequate individualisation
the practitioner’s clinical input was not always sufficient, including in relation to providing mental health services.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering or initiating MBS Items 36, 721, 723, 2713, 2715, 2717 and 66653. The practitioner agreed to repay $417,500, to be disqualified from providing MBS item 721, 723, 2715, 2717, 92024, 92025, 92116 and 92117 services for 12 months, to be disqualified from providing MBS item 36 and 91801 services for 9 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 707, 721, 723, 732, 10997, 11610, 92016, 92068, 92069 and 92072 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 705, 707, 715, 721, 723, 732, 10997, 11610, 92016, 92068, 92069 and 92072, and had no persisting concerns in relation to MBS items 705, 723, 92016, 92068 and 92069. The Director had persisting concerns in relation to the remaining items that:

the practitioner did not always provide sufficient clinical input. For example, some health assessment documents appeared to be prepared by a nurse with little or no input from the practitioner and, on other occasions, it was not clear a health assessment service was provided.
the practitioner’s record-keeping was inadequate. Assessments made in providing CDM services was not always recorded and documentation for these services was not always sufficiently individualised
MBS requirements were not always met. For example, the practitioner did not always undertake a meaningful review when providing MBS item 732 and 92072 services.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 707, 715, 721, 732, 10997, 11610 and 92072. The practitioner agreed to repay $45,000, and will be counselled by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721, 723, 732, 2504, 2521, 2552, 5040 and 10997 in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 721, 723, 732, 2504, 2713, 5040 and 10997, and had no persisting concerns in relation to MBS items 2713 and 5040. The Director had persisting concerns in relation to the remaining items that:

the practitioner’s records for chronic disease management services were reliant on templates that were not always individualised to the patient and did not reflect that the MBS requirements had been met
the practitioner’s record-keeping was inadequate. For example, there was not always a record of mental health history and examination for MBS 2713 services.
MBS requirements, including minimum time requirements where relevant, were not always met.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 721, 723, 732, 2504 and 10997. The practitioner agreed to repay $125,000, to be disqualified from providing MBS item 732 and 92028 services for 12 months, and will be counselled by the Director.

B. No further action decisions

Request to review a general practitioner

During the review period, the practitioner rendered more Medicare services, excluding MBS Group A44 services, than 99% of their peers. The Director reviewed a random sample of services rendered as MBS items 23 and 5020. After reviewing the practitioner’s records, the Director formed the view that no further action was required as there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

Request to review a general practitioner

During the review period, the practitioner rendered MBS items 23, 703, 715 and 10660 in excess of 99% of their peers. The Director reviewed a random sample of services rendered as MBS items 23, 703, 715, 5020 and 10660. After reviewing the practitioner’s records, the Director formed the view that no further action was required as there were insufficient grounds on which a Committee could reasonably find that the practitioner engaged in inappropriate practice during the review period.

C. PSR Committee final determinations

No final determinations came into effect in July 2023

D. Federal Court

No final decisions concerning PSR were handed down in July 2023

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

No matters were referred to the major non-compliance (fraud) division in July 2023.

F. Referrals to AHPRA (106XA/B)

2 matters were referred to AHPRA in July 2023.