Monthly Snapshot This month’s PSR reporting includes 11 section 92 agreements effective November 2025, and a PSR Committee final determination effective 14 November 2025. Across both domestic and international developments, a consistent picture emerges: payment integrity risk is structural, scalable, and governance dependent. Where controls are weak, documentation poor, or oversight fragmented, fraud and abuse proliferate rapidly - often faster than enforcement can respond.

Australia — PSR Outcomes Reported This Month

Section 92 agreements (effective November 2025): 11, and one PSR Committee final determination, involving practitioners across multiple specialties. Practitioner breakdown:

• 7 General practitioners
• 1 Psychiatrist
• 1 General physician
• 1 Obstetrician–gynaecologist
• 2 Diagnostic radiologists

Financial impact:

• Repayments ranged from $10,000 to $420,000
• Highest repayment: $420,000, paid by a diagnostic radiologist / nuclear medicine specialist

Disqualification periods: these ranged from no disqualification at all 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, the obstetrician–gynaecologist, and one diagnostic radiologist, while the highest sanction—a three-year, whole-of-MBS disqualification—was imposed following the PSR Committee determination on a GP. Common themes across agreements:

• minimum time requirements not met
• documentation failed to demonstrate item requirements
• templated, copied or near-identical notes
• non-contemporaneous record-keeping
• services not clinically indicated or not properly requested (notably imaging)
• referral failures, particularly where consultation items were co-billed with procedures or imaging
• telehealth and phone services lacking evidence of patient engagement
• prescribing concerns in multiple matters

Notable risk clusters (high-level):

• Psychiatry / consultation and interview items: misuse of time-based and “initial diagnostic evaluation” items, failure to identify interviewed persons, inadequate safety-netting, and poor records.
• General practice CDM, mental health and investigations: lack of meaningful contribution, eligibility failures, unclear clinical indication, and template-driven documentation.
• Phone and telehealth items: prescribed patterns of excessive volume with no exceptional circumstances and weak records.
• Radiology and diagnostic imaging: consultation items without a separate consultation, invalid referrals, incorrect item purpose, inappropriate co-billing, missing reports, and unnecessary radiation exposure.
• General physician: One general physician ranked first nationally for prolonged attendance items relating to patients in imminent danger of death (MBS items 161 and 162), and above 99% of peers for consultant attendance and discharge case conference items (132, 133 and 834). The Director formed persisting concerns that the clinical acuity and time requirements were not consistently supported by the medical records, including uncertainty as to whether patients met the required morbidity thresholds, whether the practitioner personally attended for the claimed durations, and whether patients were in imminent danger of death. Claimed discharge case conferences were also not always substantiated. Record-keeping was found to be inadequate, including non-contemporaneous entries and insufficient clinical detail.
• Obstetrician–gynaecologist: One obstetrician–gynaecologist rendered consultation and diagnostic imaging services at volumes exceeding 99% of peers. The Director found that consultation items were not always supported by a valid referral, and that duplex scanning services were frequently claimed without meeting MBS requirements, including instances where services were not clinically indicated or specifically requested.

PSR Committee Final Determination Committee 1557 — effective 14 November 2025 The Committee found inappropriate practice in relation to multiple time-based and after-hours attendance items, with findings that included:

• failure to meet minimum time thresholds
• services not delivered in required settings or timeframes
• inadequate clinical assessment and management
• inadequate medical records, lacking history, examination findings, clinical reasoning and medication detail

Outcomes:

• reprimand
• repayment of approximately 100% of Medicare benefits paid for the relevant items
• full disqualification from MBS services for three years

Integrity Signals (Domestic) This month’s outcomes reinforce that:

• documentation integrity is the legal foundation of payment
• time-based items remain the dominant risk vector
• telehealth and phone items continue to enable high-volume misuse
• billing non-compliance and clinical governance failures are converging, increasing patient harm risk

Read the full report here.

Fraud, waste and abuse around the world

Recent international developments reported in December 2025 underline that payment-integrity failures are not jurisdiction-specific but arise wherever large public funds flow through weak or rapidly deployed systems. United Kingdom — COVID-Related Public Fund Fraud A UK government-commissioned report found that fraud during COVID-19 support schemes inflicted an estimated £10.9–11 billion loss on UK public finances. The report identified insufficient early fraud controls, weak accountability mechanisms, poor data quality and limited recovery as key contributors to the scale of loss. Integrity insight: Large-scale public funding programmes, particularly those implemented rapidly, create exceptional fraud exposure when preventive controls and verification systems are deferred. Read the full report here. United States — $1 Billion Medicare Fraud Conspiracy In December 2025, the CEO of a healthcare software company was sentenced in the United States for a more than US $1 billion Medicare fraud conspiracy, involving the generation of false physician orders used to support improper claims submitted through telemedicine and telemarketing networks. The court imposed a lengthy prison sentence and ordered hundreds of millions of dollars in restitution. Integrity insight: Digitised claiming platforms and telehealth pathways can be rapidly weaponised at scale when governance, authentication and clinical verification controls are inadequate. Read the full report here. Global Takeaways

• 💸 Fraud follows funding — particularly where money flows quickly and at scale
• 📄 Documentation is the legal gateway to lawful payment
• 📊 Technology enables both fraud and enforcement — systems must be designed for continuous scrutiny
• 🏛️ Governance failures, not just individual misconduct, drive the largest losses