Snapshot This month’s reporting covers 11 Section 92 agreements effective November 2025, one PSR Committee final determination and related regulatory and court updates. Outcomes span a wide range of specialties and service types, with repayments ranging from $10,000 to $420,000 and disqualification periods from none to three years. Across both Australian and international developments, a consistent pattern emerges: payment integrity failures arise where time, acuity, referrals, documentation and financial incentives are poorly governed. When oversight weakens, harm to patients and public finances escalates together.

Australia - Domestic Payment Integrity Outcomes

Who was involved

• 6 General practitioners
• 1 Psychiatrist
• 1 Obstetrician–gynaecologist
• 1 General physician
• 2 Diagnostic radiologists / 1 nuclear medicine specialist

Financial impact

• Repayment range: $10,000 – $420,000
• Highest repayment: $420,000, paid by a diagnostic radiologist / nuclear medicine specialist for inappropriate CT imaging and lack of clinical indication

Disqualification summary Disqualification periods ranged from no disqualification to full disqualification from all MBS services for three years, with most sanctions targeting specific high-risk items for 12–36 months. No disqualification was imposed on the general physician, obstetrician–gynaecologist, or one diagnostic radiologist, while the most severe sanction arose from the PSR Committee determination. Key Domestic Integrity Signals Time-based and acuity inflation A general physician ranked first nationally for prolonged “imminent danger of death” attendances and above 99% of peers for consultant and discharge case conference items. Records did not consistently support morbidity thresholds, personal attendance, claimed timeframes or acuity, and discharge case conferences were not always substantiated. The practitioner was ordered to repay $131,500 and was counselled. Mental health and interview items A psychiatrist ranked highest nationally for consultant interview items during initial diagnostic evaluation. Records frequently failed to identify the interviewed person, demonstrate diagnostic use of the interview, meet timing requirements, or provide adequate safety-netting for vulnerable patients. The practitioner repay $225,000, was disqualified from successor items for 12 months, and reprimanded. Chronic disease management, phone and telehealth Multiple general practitioners rendered CDM, mental health and phone/telehealth items at volumes exceeding 99% of peers. Common failures included minimum time not met, lack of meaningful contribution, template-driven records, prescribed patterns of excessive phone services, and inadequate evidence of patient engagement. Diagnostic imaging and referrals Radiology matters revealed consultation items billed without a separate consultation or valid referral, incorrect use of procedural items, inappropriate CT and MRI co-billing, missing reports, and exposure of patients to unnecessary radiation. One practitioner was ordered to repay $420,000. Obstetrics and gynaecology An obstetrician–gynaecologist rendered consultation and duplex imaging services at volumes exceeding 99% of peers. While no concerns were found with IUD insertion or pregnancy ultrasound services, consultation items were not always supported by valid referrals and duplex scans were frequently not clinically indicated or specifically requested. The practitioner was ordered to repay $320,000. Enforcement and Oversight

• PSR Committee determination: full disqualification from MBS services for three years, with repayment of approximately 100% of benefits claimed
• AHPRA referrals: two matters referred (October and November 2025). This indicates a finding that professional standards were also potentially breached triggering a patient harm signal and a required referral.

Full report here: https://www.psr.gov.au/case-outcomes/psr-directors-update-november-2025

Payment Integrity Around the World

United Kingdom - Conflicted private provision within public funding An investigation reported by BBC News revealed severe harm to women treated for breast cancer at an NHS trust, where a senior surgeon referred publicly funded patients into a privately owned clinic he controlled. The conflict of interest was not disclosed, despite estimates that the clinic billed up to £1.6 million (≈ A$3 million) per year to the NHS. Reports describe extreme surgical outliers, questionable diagnoses, unnecessary procedures and significant patient trauma. Integrity signal: undisclosed conflicts of interest in public–private care pathways create simultaneous clinical and financial risk. Full report here: Women traumatised by breast cancer treatment at NHS trust, BBC told Australia - Alleged bribery in public hospital procurement Reporting by The Sydney Morning Herald describes allegations that surgeons accepted secret payments linked to more than $2.8 million in public hospital equipment sales, with charges including official corruption and misconduct in public office. Integrity signal: procurement integrity and disclosure failures distort clinical decision-making and undermine public trust. Full report here: https://www.smh.com.au/national/surgeons-took-bribes-for-2-8-million-hospital-sales-20260115-p5nug3.html Global Takeaways

• 📄 Documentation and disclosure are the legal foundation of payment.
• 💸 Bribes and kickbacks are illegal and serious misconduct, causing both financial loss and real clinical harm.
• ⚠️Conflicts of interest undermine clinical judgment and trust, and must be declared and properly managed to protect patients and the integrity of care.
• 🏛️ Governance failures, not isolated bad actors, drive the largest losses and patient harms.

Closing Observation Across Australia and internationally, the lesson is consistent: payment integrity is not a billing problem alone. It is a system-wide discipline encompassing clinical governance, conflicts of interest, documentation integrity, referral control, procurement oversight and data transparency. Where those controls fail, patient harm and financial loss follow - predictably, repeatedly, and at scale.