Fraud, Waste and Abuse Monthly Round Up September 2025

Monthly round up A bumper edition this month! With two months of PSR case reports now published, we’re keeping the focus close to home. We’re also trying out a fresh format - starting with a snapshot, then the key details, and finishing with a month-to-month comparison. We hope you enjoy the new look, and as always, we’d love to hear what you think.

PSR Case Reports - August 2025

(Outcomes that came into effect in July 2025) Snapshot

• 12 s92 agreements (mostly GPs, plus 1 Ophthalmologist, 1 Psychiatrist)
• Top repayment: GP - $700k
• Committee determinations: 3 noted - including Dr Karynne Finniear (full disqualification 3 years + $300k)

S92 Agreements

• GPs (multiple): recurring failures on time requirements (36/44/705/707), CDM/GPMHTP eligibility (721/723/732, 2712/15/17), and after-hours criteria (585/5060). Frequent co-billing issues and universally poor records. Repayments ranged $106k–$700k, disqualifications up to 24 months.
• Ophthalmologist: improper use of 11240, 18240, 42673, 42739; $38k repay + 9-month disqualification.
• Psychiatrist: excessive extended consults, misuse of 92459, poor records; $103k repay, counselling.

Committee Findings

• Dr Karynne Finniear: inappropriate practice on 44, 2713, 5067, 91811, 91843.
  • Directions: $300k repay, reprimand, counselling, 3-year full MBS ban.
  • Issues: time/content not met, impermissible co-billing, inadequate/absent records.

Compliance Corner

• Time = time: records must substantiate duration + content.
• Eligibility first: CDM & MH items require documented conditions + plans.
• After-hours: must be urgent and within the defined period.
• Procedures + attendances: only when both services independently justified.
• Records: tailored, legible, contemporaneous.

You can access the July PSR case reports here.

PSR Case Reports - September 2025

(Outcomes that came into effect in August 2025) Snapshot

• 7 s92 agreements (5 GPs, 1 Radiologist, 1 non-GP medical practitioner)
• Highest repayment: GP - $760k (pattern of services, inadequate records)
• Longest disqualification: Medical practitioner - 36 months

S92 Agreements

• GP #1 — over-billing across attendances, after-hours, telehealth; PBS codeine/diazepam.
  • $120k repay; 12-month disqualification from 2713, 5040, 91801, and 91900.
• Radiologist — high volumes on CT/intervention; injections billed outside descriptor; co-billing not justified.
  • $309k repay; counselling.
• GP #2 — highest national volume of 44s, plus after-hours/telehealth; pattern of services with 25 days >80 attendances.
  • $760k repay; 12-month disqualification (36, 44, 599, 5060).
• GP #3 — RACF attendances and case conferences.
  • $400k repay; 12-month disqualification (743, RACF, telehealth/phone items).
• GP #4 — skin cancer work + Level D consults; unsafe excision practices, poor specimen handling, co-billing.
  • $190k repay; counselling.
• Medical practitioner — attendances + diazepam prescribing; inadequate history, illegible notes.
  • $209k repay; 36-month disqualification (36, 44, 2713).
• GP #5 — health assessments, RACF work, opioid/benzo prescribing.
  • $190k repay; counselling.

Compliance Corner

• Pattern of services (≥80 on 20+ days) is high-risk unless exceptional circumstances are crystal clear.
• Case conferences must have ≥2 other participants, with detailed notes of time, discussion and outcomes.
• Procedures + attendances: only co-bill if each service is independently justified.
• Prescribing: long-term benzos, opioids and prophylactic antibiotics draw close scrutiny; documentation must show clinical reasoning.
• Records: brief, illegible or missing = automatic concern.

You can access the August case reports here.

PSR Case Reports - July vs August 2025

Trends & Takeaways

• Repayments: Both months delivered six-figure outcomes - topping at $700k in July and $760k in August.
• Disqualifications: Escalating - July’s max 24 months; August lifted to a 36-month ban.
• Pattern of services: August showed strict enforcement where ≥80 attendances/day had no exceptional justification.
• Procedural focus:
  • July: CDM & health assessments (721, 723, 732, 705, 707, 699) with time/eligibility failures; after-hours & RACF attendances (585, 5060, 5028, 5049, 90035, 43, 51); telehealth/phone misuse (91801/02, 91900, 91910, 92024/25/28); ophthalmology billing (11240, 18240, 42673, 42738/39/88); skin excision items (31363, 31367, 45201); and prescribing scrutiny (PBS 1215Y, 3162K).
  • August: Skin excisions/flaps (45201, 31363/64), radiology interventions (18276, 57341, 59751), RACF attendances & case conferences (743, 90035/43/51), and strong action on pattern-of-services breaches.

Compliance Reminders

• Time = time — minimum durations must be real and documented.
• Eligibility first — CDM/MHTP/case conferences require clear conditions, plans, and ≥2 providers.
• Co-billing — only if each service is independently justified.
• Prescribing — opioids/benzos/antibiotics require explicit rationale in notes.
• Records — legible, tailored, contemporaneous.

The past two months have revealed some deeply concerning patterns. While the law confines its language to “inappropriate practice,” much of what was reported is plainly fraud. Billing for services that records show were never provided is not a grey area - it’s fraud. And every dollar lost is taxpayers’ money that should have been spent on genuine patient care.