Fraud, Waste and Abuse Monthly Round Up July 2025

Monthly round up Here’s a summary of PSR cases and other FWA activity

PSR Case Reports May 2025

In the month of May 4 section 92 agreements and 3 final determinations came into effect. Two of the agreements were made with General Practitioners, one with an Optometrist and one with an Ophthalmologist. Only one practitioner was disqualified, which is very unusual. The practitioner disqualified for a period of time was one of the General Practitioners. The three final determinations related to two dentists and one GP, all of whom were disqualified from billing certain items for a period. The maximum repayment across all practitioners for March was $474,467.95, which was enforced against a Dentists billing under the Child Dental Benefits Scheme. The list of practitioner failings was the same as we see every month without fail, including:

1. Inadequate records
2. No records
3. Minimum time requirements not met
4. MBS requirements not met
5. Inadequate clinical input
6. Services were not clinically relevant

One matter was referred to AHPRA in May 2025. It is worth noting that matters are referred to AHPRA if there is a concern about compliance with professional standards and/or patient safety, both of which come under AHPRA’s jurisdiction. You can access the May PSR case reports here.

FWA around the world

$14.6 Billion loss thwarted by the US Justice Department in 2025. On 30 June 2025, the US Justice Department announced the results of its Health Care Fraud investigations and prosecutions for 2025, which included criminal charges against 324 health practitioners, 96 of whom were doctors. This result more than doubles the prior record of $6 Billion. The report describes transnational criminal organizations, fraudulent wound care, prescription opioid trafficking, telemedicine and genetic testing fraud, and the usual array of typical fraud such as billing for fictitious services, up-coding and billing for phantom patients. You can read it here. Michigan Doctor Gets Four Years in Jail for $6.3Million Medicare Fraud Scheme Dr Sophie Toya, 56 years old, prescribed almost 8,000 orthotic braces to over 2,600 Medicare patients over six-months, prescribing as many as 136 braces in a day, 12 for a single patient. Undercover agents posing as Medicare beneficiaries were among the “patients” who Dr Toya prescribed the braces to. She spoke with them for less than a minute but falsely represented that she had had diagnosed the patients and the braces were medically necessary – they were not. One particularly egregious example exposed a patient to serious harm. The patient was wheelchair bound and suffering from a dangerous spinal infection that could not be treated by the braces prescribed but instead needed surgery. In Australia, Medicare does not pay for orthotic braces and the like as you would know and cases such as this remind us of the risks involved were the government ever to go down a similar path. You can read the details here. Now over to the UK. Ex-manager who stole £564,000 from NHS faces repayment or jail In Australia, it is often thought that a capitation payment system prevents fraud. I hate to burst your bubble if you have thought that, but it’s simply not true. The types of fraud just change their form – workforce and procurement fraud become more common, as this case demonstrates, In August 2023, Former NHS Manager, Thomas Elrick, 58, was sentenced to three years and eight months in jail, after he pleaded guilty to a single charge of fraud by abuse of position. He admitted to defrauding the now defunct NHS Harrow Clinical Commissioning Group out of £564,484 while he was the Assistant Managing Director, able to approve invoices up to £50,000. Between August 2018 and December 2020, Elrick approved and paid multiple invoices submitted by a company he owned – later found to be a ghost company. The payments were made into his company’s bank account but the investigation found that the company did not deliver any services or work for the NHS. You can read the details here.