Fraud, Waste and Abuse Monthly Round Up November 2025

Monthly Round-Up Another full month of PSR activity - and once again, general practice dominates the field. September 2025 saw nine new s 92 agreements, with repayments ranging from $45,000 to $500,000, and a single cardiologist topping the charts. No new committee determinations were recorded for the month, but one July case (Committee 1614) is worth revisiting for its comprehensive findings on poor documentation, excessive attendances, and misuse of both MBS and PBS items. Beyond Australia, health-system integrity has been making headlines worldwide. In Canada and South Africa, major corruption cases exposed the misuse of public health funds - from insider bid-rigging on a C$300 million hospital redevelopment to the R2 billion looting of a public hospital through fraudulent procurement. These cases remind us that fraud follows the funding, and that healthcare vulnerabilities - whether in billing, procurement, or governance - are universal.

PSR Case Reports – October 2025

(Outcomes that came into effect in September 2025) Snapshot

• 9 × s92 agreements (6 GPs + 1 Cardiologist + 1 O&G + 1 Medical Practitioner)
• Top repayment: Cardiologist – $500k
• Longest disqualification: 12 months (multiple GPs)
• Committee determinations: None new; prior case 1614 revisited

Section 92 Agreements Cardiologist — High-volume provider of item 110 (initial attendance), with services exceeding 99% of peers for 11714, 11729, 55127 and 61345.

• Issues: inadequate clinical input, unclear indications, poor records.
• Outcome: $500k repay; reprimand + counselling.

Obstetrician & Gynaecologist — Second-highest national volume of 55278 (duplex scanning); excessive 55700 use.

• Issues: billed item 104 without personal attendance; unrequested scans.
• Outcome: $310k repay; counselling.

Medical Practitioner — Highest national volumes for 279/282 (mental health) and heavy PBS prescribing (buprenorphine, diazepam, quetiapine).

• Issues: failed time/content criteria; off-label prescribing; poor documentation.
• Outcome: $165k repay; 6-month ban on 57/279/91805/91913/92121/92133; reprimand + counselling.

GP #1 — Ranked 10th for 91801 (telehealth ≥ 20 min); high volumes of MRI initiations and pathology orders.

• Issues: time not met; phone vs video confusion; poor CDM plans; non-indicated imaging.
• Outcome: $210k repay; 12-month ban on 965/967/92029/92030; reprimand + counselling.

GP #2 — Ranked 3rd for item 23 (Level B); breached pattern-of-services (≥80 attendances on 22 days).

• Issues: billing Level B for simple tasks (vaccinations); templated notes.
• Outcome: $290k repay; counselling.

GP #3 — Excessive 721/723/732 (CDM) and telehealth items.

• Issues: missing/poor plans; no collaboration; insufficient telehealth input.
• Outcome: $125k repay; 12-month ban on 965/967/92029/92030; reprimand + counselling.

GP #4 — Excessive 91801/91891/92210 (phone/after-hours) services.

• Issues: 30+ phone attendances on 45 days without exceptional circumstances.
• Outcome: $45k repay; reprimand.

GP #5 — Heavy 44/91890 usage; pattern-of-services breach (30+ phone attendances on 51 days).

• Issues: time failures; inadequate records.
• Outcome: $65k repay; reprimand + counselling.

GP #6 — Second-highest national 91891 (phone attendance ≥ 6 min) volume + high PBS use (codeine, temazepam, oxycodone, diazepam).

• Issues: time failures; weak clinical justification; unsafe prescribing; inadequate records.
• Outcome: $110k repay; reprimand + counselling.

Committee Determinations No new final determinations took effect in September. Previously finalised – Committee 1614 (July 2025): General practitioner found to have engaged in inappropriate practice across MBS 36, 44, 5040, 5060, 91809, 30064 and PBS 8319W.

• Outcome: $145k repay (~100% of benefits); reprimand + counselling; 12-month ban (36/44/5040/5060); 6-month ban (91891).
• Findings: inadequate records; minimal clinical input; co-billing without justification; misuse of antibiotics.

Compliance Corner

• Time = time: minimum durations must be met and documented.
• Personal attendance: delegation to sonographers or counsellors ≠ specialist consultation.
• Telehealth vs phone: only bill video items when video actually used.
• CDM plans: require personalised content and genuine team collaboration.
• Pattern of services: 80 face-to-face or 30 phone attendances on 20+ days = automatic PSR investigation.
• Records: must clearly show history, exam, management and follow-up for each consultation.

📖 You can access the September PSR case reports here. Trends & Takeaways (Sept vs Aug 2025)

• Repayments: consistent six-figure range ($45 k – $500 k), median ~$200 k.
• Scope: strong focus on telehealth, CDM plans and mental health items.
• Disqualifications: steady pattern of 6–12 months for repeat MBS failures.
• Documentation: continues as the primary failure across every case.
• PBS scrutiny: strong attention to benzodiazepines, opioids and antibiotic rationales.

The September round demonstrates a tight focus on volume outliers and poor record-keeping across specialties. Even where clinical practice appeared reasonable, deficient notes remained fatal - and as the PSR makes clear, if it’s not in the record, it didn’t happen.

FWA Around the World

Two major health-sector scandals made global headlines this month - one in Canada, the other in South Africa. Both show that fraud, waste and abuse aren’t confined to billing or rebates: they thrive wherever public money meets weak oversight. Canada – Hospital Redevelopment Procurement Fraud In October 2025, two senior figures were found guilty of fraud in relation to the C$300 million St Michael’s Hospital redevelopment project in Toronto. A former executive of Bondfield Construction Co. Ltd. and a senior hospital executive were convicted of providing and using confidential bid-evaluation information during the tender process — effectively rigging the outcome. The court found that the hospital insider leaked detailed procurement scoring data to Bondfield’s president, allowing the company to undercut competitors and win the major hospital expansion contract. This case follows a decade-long investigation into corruption in Ontario’s hospital-building program and highlights how public–private partnerships (PPPs) in health can create fertile ground for conflicts of interest and kickbacks when transparency fails. Why it matters for Australia: Even though this was not a clinical billing case, the fraud targeted the infrastructure funding pipeline — an increasingly relevant area as Australia invests heavily in hospital redevelopment, digital health, and private-sector partnerships. It’s a reminder that health-system fraud isn’t confined to claims and rebates: procurement, governance, and insider access can be just as costly. 📖 Read the Canadian judgment summary here. South Africa – Tembisa Hospital Procurement Scandal I was actually in Cape Town attending a conference when this story was exploding in the media. Everyone at the conference was talking about it. In September 2025, South Africa’s Special Investigating Unit (SIU) released its interim report on the Tembisa Hospital procurement scandal, exposing more than R2 billion (≈ A$160 million) in fraudulent contracts and irregular payments. The SIU examined 4,500 purchase orders and 207 suppliers, uncovering a network of collusive syndicates - one alone responsible for R816 million in payments. Investigators found widespread abuse of the “three-quote” system, where purchases were deliberately kept below R500,000 to bypass public-tender requirements. The consequences have been devastating. The looting of hospital funds has been directly linked to shortages of medicines, food, and basic supplies, and several officials, from clerks to senior managers, now face charges for corruption and money-laundering. Why it matters for Australia: This case extends the fraud conversation beyond billing and into procurement and supply-chain risk. The deliberate splitting of invoices to evade oversight mirrors techniques used in health-service contracting worldwide. It’s a potent reminder that financial misconduct in healthcare directly translates into patient harm - empty shelves, delayed care, and public mistrust. 📖 Read the SIU’s interim report here. Global Takeaways

• 💸 Fraud follows the funding: Whether it’s fee-for-service, capitation, or capital works, wherever large health budgets flow, exploitation follows.
• 🏥 Procurement fraud is nothing new: It’s always been part of the landscape — it just depends on the payment model. In systems like the UK’s NHS, where there’s no fee-for-service billing, procurement and contracting fraud are more common, while in fee-for-service systems, claims fraud dominates.
• 📋 Transparency is the antidote: Strong audit trails, supplier vetting, and open reporting are as essential to system integrity as accurate billing.