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 1^st and 2^nd 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% of their peers. Findings against this practitioner were that they didn’t attend the patient for some of the consultations billed (that is actually fraud), they billed telehealth appointments as in-person consults, billed initial consults when they were not initial, and their record keeping was inadequate. This practitioner will repay $72,000 and has been disqualified from billing one of the home visit items for 12 months. You can access the December PSR case reports here.

FWA around the world

Former nurse practitioner sentenced to five years in prison for health care fraud Tristan Ashley Svejkovsky, aged 41was sentenced to five years in prison, and three years of supervised release, after pleading guilty to falsely billing an insurance company of approximately $62 million for vitamin B-12 injections some of which did not occur, and others were upcoded to increase the number of units she billed. In Australia this would be the equivalent of upcoding anaesthetic units for financial gain. She received approximately $613,108 for these false claims. The defendant also pleaded guilty to using the registration number of another nurse practitioner after hers was cancelled. Svejkovsky was also ordered to pay $613,108 in restitution. You can read the Department of Justice report here. Greenfield Man Sentenced to 15 months in prison for paying kickbacks Mohammed Kazim Ali was sentenced to 15 months in prison for paying illegal healthcare kickbacks and was ordered to pay over $2.2 million in restitution to Medicaid and Medicare plus a $75,000 fine. Ali and his co-defendant, Justin Hanson, owned a Milwaukee-area clinical laboratory called Noah Associates. For three years Ali and Hanson paid kickbacks to the owner of a Milwaukee substance use treatment clinic in exchange for referrals of Medicaid and Medicare patients for unnecessary urine drug tests which were performed by Noah Associates.  Medicaid and Medicare paid Noah Associates over $2.2 million for the unnecessary tests.  Ali personally received over $800,000 from Noah Associates during the scheme. Ali has been excluded from future participation in the Medicare and Medicaid schemes and his co-defendant, Hanson, has also pleaded guilty and will be sentenced on 21 March 2025. You can read the Department of Justice report here. Greensboro Laboratory and Owner Agree to Pay $850,000 to Resolve Allegations of False Claims for Urine Drug Testing In another urine drug testing matter, Substance Abuse Treatment Labs and its owner, Paul Fribush, agreed to pay $850,000 to resolve civil allegations that it violated the False Claims Act by billing North Carolina Medicaid for medically unnecessary urine drug screening tests. It was alleged that Substance Abuse Treatment Labs and Fribush not only submitted claims for unnecessary tests but upcoded them to the highest available dollar amount. This is a civil settlement which means there were no findings of liability. You can read the Department of Justice report here. Pain Specialist Agrees to Pay $3.5 Million to Settle False Claims and Control Substances Allegations Dr Kamal Kabakibou and his medical practice, “The Center for Pain Management,” have settled claims arising from allegations of billing for unnecessary testing (including urine drug tests – again!) and pre-signing opioid prescriptions to be dispensed by a nurse practitioner while Dr Kabakibou was overseas. Kabakibou and his practice will pay $3.5 million to the United States and have agreed to submit regular monitoring reports to the Drug Enforcement Administration for the next five years. In addition, Kabakibou and his medical practice have entered a three-year integrity agreement with the U.S. Department of Health and Human Services Office of Inspector General, which includes an annual claims review by an independent review organization. We think a similar process of independent claims reviews in Australia is needed. This is a civil settlement which means there were no findings of liability. You can read the Department of Justice report here.