Snapshot This month’s reporting covers 8 Section 92 agreements effective December 2025. Outcomes span psychology, diagnostic radiology and general practice, with repayments ranging from $30,000 to $600,000 and sanctions including counselling, reprimands and targeted disqualifications. Total repayments across the matters: $2,071,000 Average repayment per practitioner: $258,875 Across the matters reviewed, recurring integrity risks included:

• failure to meet minimum time requirements
• billing services where patient attendance was absent
• high-volume service patterns exceeding peer benchmarks
• inadequate or retrospective clinical records

Emerging system signal Public scrutiny of payment integrity intensified following the ABC Four Corners investigation into endometriosis surgery, which raised concerns about the billing of MBS item 35641 (Stage IV endometriosis) in circumstances where operative findings and pathology did not support severe disease. When procedural coding is tied to clinical severity, weak verification controls can expose both patients and public finances to significant risk simultaneously. Australia - Domestic Payment Integrity Outcomes Who was involved

• 6 General practitioners • 1 Psychologist • 1 Radiologist

Financial impact

• Repayment range: $30,000 – $600,000 • Highest repayment: $600,000, paid by a GP following concerns across chronic disease management services, health assessments, skin excisions and prescribed patterns of services.

Disqualification summary Disqualification periods ranged from no disqualification to targeted item restrictions for 12 months. Disqualification was imposed in three matters affecting:

• eating disorder psychological treatment services
• chronic disease management and telehealth items
• health assessment services.

Other practitioners were subject to repayments, counselling or reprimands without disqualification. Key Domestic Integrity Signals Time-based psychological treatment services The first psychologist we are aware of to come under PSR scrutiny was found to have rendered the highest national volume of item 82365 and among the highest volumes of item 91184 services. Concerns included:

• services billed when the patient was absent despite personal attendance requirements
• minimum time thresholds not met
• inadequate clinical records

Outcome:

• Repayment $165,000
• Counselling
• 12-month disqualification from item 82365

Diagnostic imaging A radiologist rendered the largest number nationally of musculoskeletal ultrasound services (item 55850). Review identified:

• systemic billing error affecting item 55054
• co-billing of excluded items with ultrasound services.

Outcome:

• Repayment $30,000
• Counselling

High-volume general practice services Several general practitioners rendered services in excess of 99% of peers, including consultation, RACF attendance, chronic disease management and telehealth items. Common integrity failures included:

• minimum time thresholds not met
• inadequate or retrospective clinical records
• lack of clinical indication
• unclear evidence of patient contact for phone services
• incomplete chronic disease management plans

Repayments ranged from $35,000 to $590,000. Prescribed patterns of services Multiple practitioners triggered the prescribed pattern provisions, including:

• 80+ services on 20 or more days within a 12-month period
• 30+ phone services on 20 or more days

In several cases the PSR concluded no exceptional circumstances existed to justify these service volumes. Chronic disease management and health assessments One practitioner ranked among the highest national users of GP management plans, team care arrangements and mental health plans. Concerns included:

• inadequate documentation
• lack of clinical relevance for some services
• co-billing where necessity was unclear.

Outcome:

• Repayment $600,000
• Counselling and reprimand
• 12-month disqualification from selected health assessment items

Enforcement and Oversight All eight matters were resolved through Section 92 agreements, meaning practitioners acknowledged inappropriate practice and agreed to sanctions without referral to a PSR Committee. Sanctions included:

• repayments from $30,000 to $600,000 • counselling by the Director or Associate Director • formal reprimands • targeted item disqualification for 12 months

Full report here: https://www.psr.gov.au/case-outcomes/psr-directors-update-december-2025 Payment Integrity Around the World Australia – Endometriosis surgery and billing integrity An ABC Four Corners investigation broadcast in February examined allegations that a Melbourne gynaecologist performed extensive endometriosis surgery on women who did not have severe disease, with pathology reports in some cases identifying little or no endometriosis present. The investigation raises serious payment integrity questions, including the billing of MBS item 35641, which is reserved for severe (Stage IV) endometriosis requiring extensive laparoscopic resection. Integrity signal: where severe disease coding does not align with operative findings and pathology, billing integrity and patient safety risks arise simultaneously. Full report here: https://www.abc.net.au/news/2026-02-23/endometriosis-gynaecologist-simon-gordon-complaints-four-corners/106361726 Australia – Alleged surgical device kickbacks Queensland surgeons and a medical device company director appeared in court in early 2026 over allegations of a $2.8 million kickback scheme involving surgical equipment supplied to public hospitals. Investigators allege that undisclosed payments were made to surgeons in exchange for the use of particular surgical devices during hospital procedures. The matter forms part of a broader investigation led by the Queensland Crime and Corruption Commission into corruption risks in public hospital procurement. Integrity signal: undisclosed financial relationships between clinicians and suppliers create direct conflicts of interest, distorting procurement decisions and potentially influencing clinical care. Full report here: https://www.abc.net.au/news/2026-01-15/three-men-accused-of-qld-hospital-fraud-in-court/106232710 United States – $145 million healthcare fraud sentencing A Texas physician was sentenced in February 2026 to 8.5 years in prison following conviction in a US$145 million healthcare fraud scheme involving fraudulent billing to federal health programs. Authorities alleged the scheme involved billing for services that were not medically necessary and manipulating claims to obtain higher reimbursements. Integrity signal: large-scale billing fraud frequently combines documentation manipulation with inflated service coding, enabling long-running schemes before detection. Full report here: https://www.justice.gov/opa/pr/texas-doctor-sentenced-85-years-prison-145-million-health-care-fraud-scheme United States – Unlicensed doctor billing Medicaid Authorities in Connecticut charged a man who posed as a doctor and treated patients despite having no medical licence, while services were billed to insurance under another practitioner’s name. Investigators allege the individual examined patients, diagnosed conditions and prescribed medications while falsely representing himself as a physician. Integrity signal: provider identity fraud remains a persistent vulnerability in healthcare payment systems. Full report here: https://www.ctinsider.com/journalinquirer/article/east-hartford-fake-doctor-siddiqui-quraishi-21331094.php Global Takeaways

• 📄 Clinical documentation and pathology evidence must support procedural complexity and billing severity.
• ⏱️ Time-based and severity-based billing models are consistently vulnerable to inflation when governance weakens.
• 💸 Financial incentives embedded in referral pathways, prescribing and treatment intensity can distort clinical decision-making.
• 🌐 Telehealth and digital care models introduce new payment integrity risks if documentation and verification controls do not scale with them.
• 🏛️ Across jurisdictions, the largest losses arise from governance failures rather than isolated misconduct.

Closing Observation Across Australia and internationally, the lesson remains consistent: payment integrity is not a billing problem alone. It is a system-wide discipline involving clinical governance, documentation integrity, referral control, conflict management and transparent data oversight. Where those controls weaken, patient harm and financial loss follow - repeatedly and at scale.