Context
Australia Snapshot
This month’s reporting covers 2 Section 92 agreements effective January and February 2026 and 5 PSR Committee final determinations. Outcomes span 5 general practitioners and 1 radiologist, with repayments ranging from $140,000 to $630,000 and sanctions including counselling, reprimands and targeted disqualifications. The highest repayment was $630,000, paid by a GP. Across the matters reviewed, recurring integrity risks included: • failure to meet minimum time requirements • billing services where patient attendance or practitioner involvement was absent or unclear • high-volume service patterns exceeding peer benchmarks • inadequate, templated or retrospective clinical records • billing care planning services without evidence of meaningful clinical input or implementation Disqualification summary Disqualification periods ranged from no disqualification to targeted item restrictions for up to 36 months. Key areas of concern Section 92 agreements – high-volume general practice Two general practitioners entered Section 92 agreements following concerns about service volumes significantly exceeding peer benchmarks. Concerns included: • inadequate and insufficiently personalised records • failure to meet minimum time requirements • lack of clinical reasoning for prescribing • chronic disease management services lacking sufficient clinical input • billing patterns designed to avoid same-day restrictions • prescribed patterns of services, including 80+ services per day across more than 200 days Outcomes: • Repayments of $300,000 and $380,000 • Disqualification from CDM replacement items for 9 and 12 months • Reprimand in one matter Diagnostic imaging – radiology A radiologist was found to have engaged in inappropriate practice across CT and PET imaging services. Concerns included: • absence of valid requests • clinically unnecessary or duplicative imaging • billing for patients who did not meet eligibility criteria • failure to produce reports for billed services Outcome: • Repayment $140,000 • Reprimand • Counselling General practice attendances Multiple final determinations identified consistent failures across attendance, telehealth, after-hours and mental health items. Common issues included: • minimum time thresholds not met • inadequate and non-contemporaneous records • insufficient clinical input • failure to take or document appropriate history and examination • telehealth services lacking evidence of patient contact • services delivered by others but billed as practitioner attendances Repayments ranged from $400,000 to $630,000. Chronic disease management items again featured prominently across matters. Concerns included: • absent or inadequate documentation • generic and duplicated plans • lack of collaboration with other providers • failure to individualise goals or actions • billing on different days to avoid co-billing restrictions • reviews with little or no meaningful amendment Procedural and co-claiming irregularities Findings across procedural items included: • co-billing attendances without separate clinical input. • failure to meet item-specific requirements • inadequate consent and documentation • poor follow-up practices • acupuncture services lacking clinical justification or time evidence PBS prescribing integrity One matter identified concerns with prescribing practices, including: • lack of clinical indication • insufficient documentation supporting prescriptions • inadequate patient history relevant to prescribed medications This reinforces the alignment between prescribing integrity and billing integrity failures.Payment Integrity Around the World
United States – $500 million healthcare fraud prosecutions (April 2026) The US Department of Justice announced coordinated civil and criminal actions in April 2026 targeting schemes attempting to defraud taxpayer-funded health programs of over $500 million. The cases included fraudulent Affordable Care Act enrolments and other large-scale billing schemes involving multiple defendants and entities.Full report here: https://www.justice.gov/opa/pr/justice-department-prosecutes-half-billion-dollars-healthcare-and-covid-fraud-schemes
United States – Telehealth fraud and AI-enabled schemes (March 2026) Recent enforcement activity identified telehealth-linked fraud schemes where services and prescriptions were approved without meaningful patient interaction, including emerging use of AI and impersonation techniques. Authorities have charged thousands of individuals collectively responsible for tens of billions in fraudulent billing across healthcare programs and insurers. Integrity signal: when clinical decision-making is decoupled from real patient contact, digital care models allow fraud to scale rapidly and invisibly. Full report here: https://cybernews.com/news/telemedicine-ceo-admits-to-a-46m-fraud-scheme/ United States – Post-payment system vulnerability (March 2026) A 2026 financial intelligence advisory highlighted that healthcare fraud continues to be one of the largest sources of illicit proceeds, with reporting increasing significantly in recent years. Authorities noted that detected activity likely represents only a fraction of total fraud occurring within the system. Integrity signal: post-payment monitoring captures only a subset of fraud, meaning the majority of losses occur before detection. Full report here: https://www.fincen.gov/system/files/2026-03/FinCEN-Advisory-Health-Care-Fraud.pdf Global Takeaways- Documentation integrity remains the primary control point for billing compliance • Time-based billing models are consistently vulnerable to inflation • In Australia, care plans are highly susceptible to templating and administrative misuse • Telehealth introduces scale without necessarily introducing verification • The largest losses arise from system design weaknesses, not isolated misconduct
