PSR Director's update for May 2025

A. Section 92 agreements effective in May 2025

Four agreements entered into by the Director or an Associate Director and persons under review (under section 92 of the Act) came into effect in May 2025.

General practitioner

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

• 707 (professional attendance to perform a prolonged health assessment – at least 60 minutes)
• 723 (coordination of team care arrangements (TCAs))
• 732 (review of a GP management plan (GPMP) or TCAs)
• 743 (attendance to organise and coordinate a multidisciplinary case lasting at least 40 minutes)
• 2700 (attendance to prepare a GP mental health treatment plan (GPMHTP) – 20 to 40 minutes)
• 5049 (after-hours attendance at a residential aged care facility (RACF) – at least 20 minutes)
• 90043 (attendance at a RACF – at least 20 minutes)
• 91801 (video attendance – at least 20 minutes)
• 92004 (video attendance for a health assessment)
• 92024 (video attendance to a prepare a GPMP)
• 92025 (video attendance to coordinate a TCA)
• 92027 (contribution or review of a multidisciplinary care plan by telehealth, at a RACF)
• 92028 (video attendance to review a GPMP or TCAs)
• 92210 (after-hours video attendance by a general practitioner for a condition requiring urgent assessment)
• 92211 (after-hours video attendance by a medical practitioner for a condition requiring urgent assessment)

The Associate Director reviewed this practitioner’s rendering of MBS items: 

• 23 (attendance – less than 20 minutes)
• 36 (attendance – at least 20 minutes)
• 707
• 721 (preparation of a GP management plan)
• 723
• 732
• 90035 (attendance at a RACF – less than 20 minutes)
• 90043
• 91891 (phone attendance – at least 6 minutes)
• 92028

The Associate Director had persisting concerns that the practitioner’s record keeping was inadequate. There were no records for some patients and insufficient and poor records for some patients. Their records were particularly poor for RACF patients.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 23, 36, 707, 721, 723, 732, 90035, 90043, 91891 and 92028 services. The practitioner agreed to:

• repay $300,000
• be disqualified from providing MBS item 707, 721, 723, 92024, 92025, 92028 services for 12 months
• be disqualified from providing MBS item 36, 732, 90043, 91801, 91891, 91900 services for 6 months

and will be reprimanded and 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
• 44 (professional attendance – at least 40 minutes)
• 91801
• 91802 (video attendance – at least 40 minutes)
• 735 (organising a GP case conference between 15 and 20 minutes)
• 739 (attendance to organise and coordinate a case conference)
• 4001 (pregnancy support counselling services, surgery consultation)
• 92136 (telehealth attendance at least 20 minutes in duration, for providing non‑directive pregnancy support counselling)

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

• 36
• 44
• 4001
• 16500 (antenatal attendance)
• 91801
• 91853 (antenatal telehealth attendance)

The Director had persisting concerns that:

• the practitioner did not always complete a progress note of the service and some attendances were not always supported by a contemporaneous record
• the practitioner did not always take an adequate history or perform a clinically relevant examination of observations
• MBS minimum time requirements were not always met, especially when co‑billed with non‑directive pregnancy counselling services
• the MBS requirements were not always met for attendance for therapeutic antenatal services rendered by the practitioner. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 36, 44, 4001, 16500, 91801 and 91853. The practitioner agreed to repay $40,000, and to be counselled by the Director. 

Optometrist

During the review period, the practitioner rendered MBS item 10914 (professional attendance – 15 minutes, being the first in a course of attention, if the patient has a progressive disorder requiring comprehensive reassessment) in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS item 10914. The Director had persisting concerns that:

• the MBS requirements, including the requirements for a comprehensive assessment, minimum time duration, and time between assessments, were not always met
• the practitioner’s records often contained no evidence of examinations and measurements and did not always reflect an adequate level of clinical input
• the practitioner’s patient management was not always appropriate
• the practitioner’s record keeping was inadequate, including where their notes lacked sufficient clinical information or adequate amendment. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS item 10914. The practitioner agreed to repay $116,500, and to be counselled by the Director. 

Ophthalmologist

During the review period, the practitioner rendered MBS item 18240 (retrobulbar or peribulbar injection) in excess of 99% of their peers. The Director reviewed this practitioner’s rendering of MBS items 18240, 42725 (vitrectomy via pars plana sclerotomy) and 42738 (paracentesis of anterior chamber or vitreous cavity for the injection of therapeutic substances), and had no concerns in relation to MBS items 42725 and 42738. The Director had persisting concerns that the MBS requirements for MBS item 18240 were not always met because the procedure was not a genuine retrobulbar or peribulbar injection. 

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering MBS Items 18240. The practitioner agreed to repay $187,500, and to be counselled by the Director. 

B. No further action decisions

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

C. PSR Committee final determinations

PSR Committee 1426

On 23 May 2025 a final determination came into effect regarding a dentist. In the final report of the PSR Committee, the practitioner was found to have engaged in appropriate practice in connection with rendering Child Dental Benefit Scheme (CDBS) item 88011 (comprehensive oral examination), 88111 (removal of plaque and/or stain), 88114 (removal of calculus – first visit), 88121 (topical application of remineralisation and/or cariostatic agents) and 88161 (fissure and/or tooth surface sealing) services during the review period. Each of the reviewed services were provided by dental therapists billed with the practitioner’s provider number.

The Determining Authority directed that the practitioner:

• be reprimanded
• be counselled
• repay the amount of $400,000. This reflects approximately 90% of the dental benefits that were paid for the CDBS item 88011, 88111, 88114, 88121 and 88161 services in connection with which they were found to have engaged in inappropriate practice
• be disqualified from rendering CDBS item 88011, 88111, 88114, 88121 and 88161 services for a period of 3 months.

In relation to the CDBS item 88011, 88111, 88114, 88121 and 88161 services the Committee made findings based on one or more of the following:

• The practitioner permitted the use of their provider number but failed to properly oversee the system of work, including as to the dental therapist’s performance of services and as to the quality of the clinical records.
• This failure from the practitioner contributed to deficiencies in the services, including that:
  • the CDBS item requirements were not met, including that informed financial consent was not obtained prior to the service and/or that the CDBS service was not performed
  • the respective CDBS service was not clinically indicated
  • the clinical input into the service was inadequate, including in relation to the management of the patient
  • the clinical record was inadequate, including in relation to its description for the service performed, the patient’s consent for treatment and whether the relevant CDBS service was clinically indicated or provided.

PSR Committee 1473

On 23 May 2025 a final determination came into effect regarding a dentist. In the final report of the PSR Committee, the practitioner was found to have engaged in appropriate practice in connection with CDBS item 88011, 88111, 88114, 88121 and 88161 services during the review period. Each of the reviewed services were provided by oral health therapists using the practitioner’s provider number, rather than by the practitioner themselves.

The Determining Authority directed that the practitioner:

• be reprimanded
• be counselled
• repay the amount of $474,467.95. This reflects the total dental benefits that were paid for the CDBS item 88011, 88111, 88114, 88121 and 88161 services in connection with which they were found to have engaged in inappropriate practice
• be disqualified from rendering CDBS item 88011, 88111, 88114, 88121 and 88161 services for a period of 18 months.

In relation to all of the CDBS items reviewed, the Committee made findings based on the CDBS requirements not being met in circumstances where the practitioner did not provide adequate supervision or oversight of the service performed. In allowing the use of their provider number for the services, the practitioner assumed responsibility as the clinical team leader, but did not have a sufficient arrangement in place with the supervised oral health therapists to ensure that services were clinically necessary and of a satisfactory standard.

In relation to CDBS item 88011 services the Committee also made findings based on one or more of the following:

• Financial consent was not sought in a way that allowed the patient’s parent or guardian to understand the consequences that the treatment decision being made by the attending oral health therapist would have on their CDBS balance.
• The clinical record was inadequate, including that it did not reflect a comprehensive oral examination of all teeth or did not include an adequate history or description of the patient’s behaviour, compliance or possible orthodontic needs.
• Insufficient clinical input was provided for some services, including inappropriate treatment planning. 

In relation to CDBS item 88111 services the Committee made findings based on one or more of the following:

• The clinical record was inadequate, including where it was superficial and lacked clinical meaning. The record does not disclose the method by which plaque or stains were removed and makes no reference to the patient’s or cooperation, which would be useful information for another dental practitioner relying on the record in the future.
• Insufficient clinical input was provided, including where treatment provided was inappropriate.

In relation to CDBS item 88114 services the Committee also made findings based on one or more of the following:

• The records are not of an acceptable standard as they are templated and deficient in findings and recording the treatment outcomes. There was no record of whether the patient coped well with the service, which would be useful information for another dental practitioner relying on the record.
• The record does not disclose the method by which calculus was removed, whether it was hand scale or ultrasonic scale, and whether a prophy brush, prophy cup and prophy hand piece were used.
• Financial consent was not sought in a way that allowed the patient’s parent or guardian to understand the consequences that the treatment decisions being made by the attending oral health therapist would have on their CDBS balance.

In relation to CDBS item 88121 services the Committee also made findings based on one or more of the following:

• Financial consent was not sought in a way that allowed the patient’s parent or guardian to understand the consequences that the treatment decisions being made by the attending oral health therapist would have on their CDBS balance.
• The application of tooth mousse for patients the subject of some services did not meet the requirements for CDBS item 88121, as it is a cariostatic agent which does not achieve remineralisation of the tooth in a single application.
• For services involving a product other than tooth mousse, and where the patient’s parent was not present, consent for treatment was not appropriately sought separately to consent for an examination and clean.
• The records are heavily template based without adequate individualisation or did not sufficiently describe the treatment provided.
• Clinical indication was not assessed. There was no clinical indication for treatment for children with a low caries risk or no caries risk.

In relation to CDBS item 88161 services the Committee also made findings based on one or more of the following:

• Financial consent was not sought in a way that allowed the patient’s parent or guardian to understand the consequences that the treatment decisions being made by the attending oral health therapist would have on their CDBS balance.
• Fuji VII is a low-quality fissure sealant material and so is appropriate only for patients where there is an issue with patient compliance or moisture control. The product was used for all CDBS item 81161 services and in no case did the clinical notes record clinical indication for using Fuji VII in preference to any other product.
• In some services fissure seals were applied:
  • to children who were recorded to have no or low caries risk, and where the record did not disclose any other clinical indication for fissure seals
  • to permanent teeth where the child was over 8 years of age without radiographs being taken first, which compromised the ability to identify caries in the tooth
  • to six or more teeth during the single consultation, which is a significant time and treatment burden for a child in one day that is not supported by the information in the clinical record and where there the record does not disclose any information about the clinical necessity for that much treatment
  • in circumstances where the child had evidence of caries, so fillings were required. This also impacted on the ability of the parent to provide informed financial consent for the placing of fissure seals, when they may have opted instead to use the CDBS funds for fillings.
• The records of the fissure sealant services are brief, and rely heavily on templates, with the result that another practitioner would have difficulty identifying what occurred during the consultation.

PSR Committee 1590

On 23 May 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 36, 705 (long health assessment lasting 45-60 minutes), 721, 723 and 2701 (attendance to prepare a GP mental health treatment plan – at least 40 minutes) services during the review period.

The Determining Authority directed that the practitioner:

• be reprimanded
• repay the amount of $250,000. This reflects approximately 76% of the benefits that were paid for the MBS item 36, 705, 721, 723 and 2701 services in connection with which the practitioner was found to have engaged in inappropriate practice
• be fully disqualified from rendering MBS item services for a period of 12 months.

In relation to MBS item 36 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 input to justify a consultation of at least 20 minutes’ duration, there was no detailed patient history or management plan recorded and there was no clinical indication recorded for recommended investigations.
• The practitioner’s clinical input into the service was inadequate.
• The practitioner did not provide a clinically relevant service for which a Medicare benefit was payable.
• The medical record was otherwise inadequate, including where there was no record for the date of service.

In relation to MBS item 705 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 perform a health assessment on the date of service, the patient was not eligible for a health assessment and/or the service did not require an attendance of at least 45 minutes’ duration.
• The medical record was otherwise inadequate.

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

• The MBS requirements were not met, including that a GPMP was not prepared on the date of service, and the patient was not always eligible for a GPMP.
• The practitioner did not provide a comprehensive written plan in relation to any of the services reviewed.

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 that there was no record of a TCA document for the date of service, the patient was not eligible for TCA, there was no evidence of two-way communication with at least 2 other providers involved in the patient’s care.
• The practitioner’s clinical input into the service was inadequate.
• The medical record was otherwise inadequate, including that the TCA was generic and not individualised to the patient’s healthcare needs.

In relation to MBS item 2701 services the Committee made findings based on one or more of the following:

• The MBS requirements were not met, including that the clinical input recorded was not sufficient to justify a consultation of at least 40 minutes’ duration and the practitioner did not prepare a GP mental health treatment plan on the date of service.
• The medical record was inadequate, including that none of the services reviewed included a mental state examination or proposed a substantive management plan.
• The practitioner’s clinical input into the service was insufficient, including in relation to the patient’s goals and monitoring their progress over time.

D. Federal Court

No federal court decisions we handed down in May 2025.

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

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

F. Referrals to AHPRA (106XA/B)

One matter was referred to Ahpra in May 2025.