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 removal of premalignant and malignant lesions. This GP was ordered to repay $200,000 and was disqualified for 12 months from billing some services and 3 months for another. You can access the November PSR case reports here.

FWA around the world

Former doctor and her wife jailed for fraud and unlawful prescribing A former family medicine doctor and her wife, who was the owner of the practice, were jailed for 87 months and 42 months respectively for fraud and illegal opioid prescribing. Francene Aretha Gayle, aged 50, and Schara Monique Davis, aged 48, were each also ordered to pay $2.2 million in restitution, forfeit $226,815, and pay a fine. Gayle admitted to the unlawful distribution of opioids and the pair admitted to having conspired to commit fraud for several years by billing insurers for office visits under Gayle’s name when she did not see the patients. They admitted knowing that their billing scheme was fraudulent. You can read the Department of Justice report here. Physical therapist jailed for health care fraud Jeffrey MacEachron, aged 60, was sentenced to three months in prison, and 27 months of home confinement after pleading guilty to defrauding insurance providers for physical therapy services (that’s physiotherapy in Australia) that were not provided to patients. MacEachron was also ordered to pay $335,098 in restitution and a $5,500 fine. For more than seven years, from 2013 through 2021, MacEachron billed insurance companies for services he didn’t provide and upcoded. Upcoding means he added extra units to his claims beyond what he actually provided. In Australia, this would be the equivalent of an anaesthetist billing more units of anaesthetic time than the anaesthetist provided, or a GP upcoding from an item 23 to a 44 but not spending the required extra time with the patient. You can read the Department of Justice report here. Three indicted in Medicaid fraud conspiracy scheme The US Medicaid scheme is a government program of health insurance for people with limited incomes. US Medicare, on the other hand, is for people who are 65 or older. This indictment relates to alleged abuse of the Medicaid scheme. Three people have been indicted with 13 charges alleging healthcare fraud. As this is only an indictment and the case has not yet been heard, the three defendants are presumed innocent until proven guilty beyond a reasonable doubt. Between March 2018 and July 2024, it is alleged that Shawn Ashley Grygo, aged 37, Shantel Rene Magadanz, aged 34, and Heather Lynn Heim, aged 46, devised and carried out a systematic fraud scheme which included billing for treatments that were not provided and billing for ineligible services. The trio allegedly targeted vulnerable, Medicaid eligible people from homeless shelters and drug treatment programs and recruited them into their fraudulent scheme, then threatened them with being locked out of free housing if they didn’t attend for unnecessary services that were being systematically overbilled. We will keep you updated with this case as it progresses through to trial. You can read the Department of Justice report here.