Monthly round up Here’s a summary of PSR cases and other FWA activity PSR Case Reports April 2025 In the month of April 3 section 92 agreements and 6 final determinations came into effect. Two of the agreements were made with General Practitioners and one with a Plastic Surgeon. All of these practitioners were disqualified from billing certain items for a period. The six final determinations related to two chiropractors and four GPs, all of whom were also disqualified from billing certain items for a period. It is quite unusual to see full disqualification from all MBS billing, but this month one GP was fully disqualified from rendering MBS item services for 24 months and another was fully disqualified for 3 months. The maximum repayment across all practitioners for March was $537,000, which was enforced against a GP. This month the troubling findings against the various practitioners were extensive including: MBS requirements were not met. Medical records were inadequate. Clinical input was insufficient or inadequate. Services were not clinically relevant. For services provided by or in part by another practitioner, a Medicare benefit was not payable, and it was inappropriate for the practitioner to bill MBS items such as 23, 721, 723, 732 and 2713. Templates were not sufficiently particularised. The MBS time requirements were not met. CT scans and pathology studies were not clinically relevant. Upcoding – billing for a longer or more complex service than was provided. Some of the procedures billed by the plastic surgeon were not clinically justified. It was a litany of poor behaviour that...

Monthly round up Here’s a summary of PSR cases and other FWA activity PSR Case Reports March 2025 In the month of March 6 section 92 agreements and 3 final determinations came into effect. One of the agreements was made with an Obstetrician and Gynaecologist, one with a Radiation Oncologist, and four with GPs. Half of these practitioners were disqualified from billing certain items for a period. The three final determinations related to a GP, a dentist and an ophthalmologist respectively. These practitioners were all disqualified from billing certain items for a period. The maximum repayment across all practitioners for March was $700,000, which was enforced against a dentist. The findings included: The consent obtained from the patients’ parents did not correctly describe the services to be performed The medical record was inadequate The practitioner was sometimes not present Removal of calculus did not take place on the date of service Fissure seals were not performed on the date of service The service was not clinically indicated These very troubling findings – billing for services not provided and billing for services when the practitioner was not even present – amount to fraud in our view, not inappropriate practice. The GP cases involved the usual litany of common findings – MBS requirements not met, services not clinically necessary, inadequate record keeping, and inadequate particularisation of templates. The agreement with the obstetrician/gynaecologist was interesting given it involved billing of the standard pregnancy planning and management item – 16590. The findings were: services billed under the practitioner’s provider number were not always personally...

Monthly round up Here’s a summary of PSR cases and other FWA activity PSR Case Reports January and February 2025 In the months of January and February 10 section 92 agreements came into effect. Seven of the agreements were made with GPs, one with a radiation oncologist, one with a psychiatrist and one with an anaesthetist. Four GPs and the psychiatrist were disqualified from billing certain items for a period. The maximum repayment across all practitioners for December was $595,000, which was enforced against a GP who rendered and prescribed MBS item 732 (review of a GPMP) and PBS item 3162K (diazepam 5mg) in excess of 99% of their peers. It is worth mentioning that the PSR is not restricted to investigating only certain MBS or PBS items. Once you are under review, the PSR can review every item you bill across your universe of claims. This GP was reviewed for numerous MBS and PBS items and was found to have breached the 80/20 rule, not met time requirements, not met item description requirements, and some services were not clinically relevant. Some patients were not eligible for the services provided and record keeping was inadequate. There was insufficient individualisation where templates had been used. This provides another reminder about templates. Copying and pasting without sufficient individualisation is regularly reported by the PSR, causing providers to fall foul of legal requirements. The radiation oncologist was not disqualified and was required to repay $300,000. This practitioner was found to have not met complexity requirements for some items and had serially upcoded others....

Monthly round up There have been no updates from the PSR since we last reported, but plenty of FWA activity around the world. FWA around the world New York doctor facing jail following conviction for $24 million Medicare fraud scheme Dr Alexander Baldonado, aged 69, was found guilty by a jury for causing over $24 million fraudulent claims to Medicare which were not medically necessary. The Australian equivalent would be that the services were not “clinically relevant” which is our legal threshold standard. Like the U.S standard, our “clinical relevance” standard also means that all services must be necessary for the treatment of the patient. Our standard therefore operates very similarly to the U.S standard. Dr Baldonado authorised hundreds of unnecessary tests for Medicare patients who attended COVID-19 testing events, but he was not treating any of them and, in many cases, he did not speak to or examine the patients prior to ordering the tests. He also billed Medicare for fictitious consultations and received illegal cash kickbacks and bribes from the owner of a medical equipment company in exchange for ordering medically unnecessary orthotic braces. Dr Baldonado has been remanded in custody and will be sentenced in June 2025. You can read the Department of Justice report here. Louisiana doctor sentenced to 87 months jail for $5.4 million healthcare fraud scheme Dr Adrian Dexter Talbot, aged 59, owned and operated clinics that accepted cash payments for patients seeking controlled substances, such as opioids. He was found to have pre-signed prescriptions for patients he did not see or examine. With...

Here’s a summary of PSR cases and other FWA activity PSR Case Reports December 2024 In the month of December 12 section 92 agreements came into effect. 10 of the agreements were made with GPs, one with an Ophthalmologist and one with a Paediatrician. Eight GPs were disqualified from billing certain items for a period. The maximum repayment across all practitioners for December was $635,000, which was enforced against a GP who was ranked 1st and 2nd nationally for billing MBS items 5067 and 90051, which are both residential aged care facility services including in the afterhours period.  The findings against this GP included that the practitioner’s record keeping was inadequate, and MBS requirements were not always met including minimum time requirements and the item 5067 services were not always provided in the afterhours period. This GP has been disqualified from billing nine MBS services for 12 months. The Ophthalmologist was not disqualified but will repay $178,000. The findings against this practitioner related to services not being clinically relevant, not that the services were not provided. This case is another reminder that the threshold requirement before you bill any MBS item is that the service must be clinically relevant, meaning necessary. It is irrelevant that you provided all elements of the service strictly in accordance with the MBS requirements if the service was not clinically necessary in the first place. Put another way, you cannot provide services just because they are there. You patients must need them. The Paediatrician billed home visits, face-to-face and telehealth consultations in excess of 99%...

Here’s a summary of PSR cases and other FWA activity PSR Case Reports November 2024 In the month of November 6 section 92 agreements and 2 final determinations came into effect. 5 of the agreements were made with GPs and 1 with an Oral and Maxillofacial Surgeon. 3 GPs were disqualified from billing certain items and/or prescribing certain medications for a period. The maximum repayment across all practitioners for November was $495,000, which was enforced against a GP who billed MBS items 23, 36 and 44 (level D consultation) and 66596 (iron studies) in excess of 99% of their peers. The findings against this GP included that the practitioner’s record keeping was inadequate, MBS requirements were not always met including minimum time requirements and there was no clinical indication for some of the iron studies. The Oral and Maxillofacial Surgeon was found to have inappropriately billed various procedures including local skin flaps, operations on the mandible or maxilla, reduction of maxillary tuberosities, wound debridement and trigeminal nerve blocks. The surgeon was required to repay $150,000, and was disqualified from claiming items 18234, 30023, 45815, 45829 for 3 months. The two final determinations were both against GPs. The first GP was found to have incorrectly billed services for patients at Residential Aged Care Facilities. This included inadequate history taking, inadequate records, missing entries for the dates of service billed, patients not needing urgent assessment when urgent items were billed and inadequate clinical input. The second GP was found to have incorrectly billed various skin lesion services including laser photocoagulation, skin flaps and...

Here’s a summary of PSR cases and other FWA activity PSR Case Reports October 2024 In the month of October 19 section 92 agreements and 1 final determination came into effect. 17 of the agreements were made with GPs, 2 with specialists (a radiologist and a rheumatologist) and the final determination was against an ophthalmologist. 9 GPs were disqualified from billing certain items and/or prescribing certain medications for a period. The maximum repayment across all practitioners this month was $625,000, which was enforced against a GP who was ranked 1st nationally for rendering item 732, 2nd for item 723 and 3rd for item 721. The findings against this GP included that the practitioner did not always attend the patient when required, did not provide adequate clinical input, and did not meet minimum time requirements for the items billed. The radiologist was found to have inappropriately billed bone densitometry services, as well as mouth x-rays and orthopantamography, and was required to repay $200,000, though was not disqualified. The rheumatologist inappropriately claimed high volumes of bone densitometry services and the aggravating factors associated with this case were egregious in our view. They included the records having incorrect details about the patient’s presentation and management, and Dexa scans being performed on patients who were ineligible for them. Inexplicably, this practitioner was neither disqualified nor required to make any repayment. The ophthalmologist was found to have inappropriately billed items 104, 42702 (lens extraction and insertion) and 42788 (laser capsulotomy). This case is a salient reminder that you cannot automatically bill a separate attendance item...