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 1^st nationally for rendering item 732, 2^nd for item 723 and 3^rd 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 every time you do a procedure. A reminder about attendance items – the law requires that you do much more than just attend. You attend the patient for the purposes of providing a clinical service, which is a consultation service. You therefore must fulfill all the requirements of each consultation service you bill. There is no Medicare rebate for saying hello to a patient on an operating theatre trolley or x-ray table. And in our world ‘clinical relevance’ is king. All these doctors provided services that were not clinically relevant meaning the patients didn’t need them. We cannot stress how important this is. We keep a database of PSR decisions, and they always make findings of patients being provided services that were not clinically relevant. We recently received a question through MBS Answers which said this: “I provide the item 116 service therefore I am legitimately entitled to claim it.” Our response will be this: “No, you are not. If the patient didn’t need it, even if you did it, no Medicare rebate is payable, and you can’t claim it.” You can access the October PSR case reports here.

FWA around the world

A doctor has been sentenced to five years in prison for defrauding an NBA player’s group health insurance. Dr William Washington billed nearly half a million dollars in one year, for services he did not provide, and then split it with his co-conspirators, who were retired NBA players. The fraudulent claims included $10,000 office visits and $25,000 shoulder injections. In addition to his jail term, Dr Washington was ordered to pay a $20,000 fine, forfeit $475,042, and pay restitution in the amount of $475,042. The FBI’s Complex Fraud and Cybercrime Unit prosecuted the case. You can read the Department of Justice report here. A former NHS senior neonatal nurse has been jailed for fraud A former neonatal nurse manager has been sentenced to five years in prison after defrauding the NHS out of almost 250,000 pounds. Tanya Maria Nasir was found guilty or various offences after a long and complex investigation. The investigation found that “Nasir had created and submitted a significant amount of fraudulent material in order to falsely secure significant positions of trust within the NHS.” You can read the NHS Counter Fraud Authority report here.