Australia Snapshot This month’s reporting covers 20 Section 92 agreements effective March 2026. Outcomes span 19 general practitioners and 1 radiologist. The largest repayment was a remarkable $3.6 million by the radiologist. GP repayments ranged from $23,000 to $700,000, with sanctions including counselling, reprimands and targeted disqualifications. Across the matters reviewed, recurring integrity risks included:

• failure to meet minimum time requirements • billing services where patient attendance or practitioner involvement was absent or unclear • high-volume service patterns exceeding peer benchmarks • inadequate or templated clinical records • billing care planning services without evidence of meaningful clinical input or implementation

Disqualification summary Disqualification periods ranged from no disqualification to targeted item restrictions for up to 24 months. Key areas of concern Diagnostic radiology and specialist attendance co-billing The standout matters this month was a radiologist who agreed to repay $3.6 million to the Commonwealth. The practitioner was in the top 1% of providers for 88 individual MBS items and was the highest ranked provider for 7 items. The Director’s concerns included unclear practitioner involvement, inadequate supervision, services performed and reported by others but signed by the practitioner under review, inadequate records, inappropriate substitution of requested services and inappropriate co-billing. Honestly, this troubling case was more fraud than anything else but we don’t use the F word (fraud) in Australia… Most importantly, the matter again highlights a persistent and costly misconception about MBS items 104 and 105. Items 104 and 105 are not “I turned up” items. They are specialist attendance items. A consultation must actually occur. There must be a valid referral. The attendance must be separate from any procedure. The record must support what happened. And in most procedural settings, items 104 and 105 cannot be billed at all. The procedure is the service. This is not a technicality. It is a fundamental Medicare billing rule. Outcome:

• Repayment of $3,600,000 • Reprimand • Counselling • 12-month disqualification from MBS items 104, 105 and telehealth equivalents

General practice Across the general practice matters, the same themes appeared repeatedly. Concerns included:

• minimum time requirements not met • phone and telehealth services billed without sufficient evidence of patient contact • high-volume service patterns exceeding peer benchmarks • prescribed patterns of services, including 30 or more phone services on 20 or more days • professional attendances with little or no clinically relevant input • services performed by practice nurses or others but billed as practitioner attendances • inadequate, copied, pasted, templated or non-contemporaneous records

Several practitioners billed very high volumes of timed attendances, after-hours attendances, phone attendances and RACF services where the records did not support that the practitioner personally rendered the service or spent the required time with the patient. The compliance lesson is simple: if the item has a time requirement, the record must support that the time was actually spent performing clinically relevant work. Chronic disease management items again featured prominently across matters. Concerns included:

• generic GPMPs and TCAs • inadequate individualisation • plans prepared for patients without qualifying chronic conditions • no evidence of meaningful two-way communication with two other health care providers • reviews with little or no meaningful amendment • duplicated or copied documentation • care plans recorded by practice nurses with unclear practitioner input • co-billing where one service appeared to form part of another

Disqualifications from CDM replacement items were common, ranging from 3 months to 24 months. Health assessments, mental health plans and after-hours items Health assessments, mental health treatment plans and after-hours items also appeared frequently. Concerns included:

• failure to meet minimum time thresholds • incomplete or templated assessments • patients not meeting eligibility requirements • urgent after-hours items billed where the patient did not require urgent assessment • RACF attendances billed where attendance on the date of service was unclear • health assessments and care plans lacking meaningful clinical input

One GP agreed to repay $700,000, the highest GP repayment this month. Procedural and co-claiming irregularities Several matters involved procedural or quasi-procedural billing concerns. Issues included:

• acupuncture services where the minimum 20-minute requirement was not met • multiple patients being attended simultaneously for acupuncture • skin lesion items billed with inaccurate or inconsistent records • therapeutic procedures co-billed with attendances where a separate attendance was not supported • diagnostic imaging initiated without sufficient clinical indication • medication review items billed without adequate consent, discussion or engagement with pharmacist recommendations

The recurring problem was not the item number alone. It was the absence of evidence that a separate, clinically relevant, billable service had occurred. PBS prescribing integrity PBS prescribing concerns appeared across multiple matters. Items included opioids, benzodiazepines, antibiotics, semaglutide and other restricted medicines. Concerns included:

• prescribing without clear clinical indication • failure to satisfy PBS restriction criteria • inadequate documentation supporting medication changes • no pain management plan • absence of relevant medication history • template records that did not support the prescribing decision

These findings reinforce the close relationship between prescribing integrity and billing integrity. Poor records rarely fail in only one direction. Payment Integrity Around the World United States – West Coast Health Care Fraud Strike Force launched The US Department of Justice launched a new West Coast Health Care Fraud Strike Force targeting schemes across Arizona, Nevada and Northern California. The DOJ said the strike force model has prosecuted more than 6,200 defendants nationally, involving more than $45 billion billed to federal health programs and private insurers. Integrity signal: data-driven, specialist enforcement bodies are becoming the global standard for healthcare fraud response. Full report here: https://www.justice.gov/opa/pr/fraud-division-launches-west-coast-strike-force-target-health-care-fraud-schemes-across United States – half-billion-dollar healthcare and COVID fraud actions The DOJ announced civil and criminal actions involving alleged schemes attempting to fraudulently bill taxpayer-funded programs more than $500 million. The matters included Affordable Care Act enrolment fraud and other large-scale schemes exploiting government-funded programs. Integrity signal: healthcare fraud is not confined to clinical billing. It also arises wherever system access, eligibility and payment rules can be manipulated. Full report here: https://www.justice.gov/opa/pr/justice-department-prosecutes-half-billion-dollars-healthcare-and-covid-fraud-schemes United Kingdom – NHS fraud, payroll and internal control failures The NHS Counter Fraud Authority reported several fraud cases involving false timesheets, fraudulent refunds, ghost contractors and abuse of internal financial access. One case involved more than £300,000 in fraudulent NHS refund claims. Another involved a former NHS manager creating ghost contractors, resulting in £123,000 paid to people who were not legitimate NHS employees. Integrity signal: payment integrity is not only about clinicians and item numbers. Internal finance systems, payroll controls, contractor validation and access controls are equally critical. Full report here: https://www.tiaa.co.uk/wp-content/uploads/2026/05/2026_Fraud-Stop-Spring-Healthcare-Issue-9.pdf Global Takeaways

• Practitioner involvement remains a fundamental billing requirement and cannot be assumed simply because a clinician's name appears on a claim
• Specialist attendance items are particularly vulnerable to misuse when billed alongside procedures or without evidence of a separate consultation
• Chronic disease management continues to be one of the highest-risk areas of Australian Medicare billing
• Time-based items remain highly dependent on documentation capable of demonstrating both duration and clinically relevant activity
• Template-driven care creates significant compliance risk when records no longer reflect the individual patient
• High-volume billing patterns remain one of the strongest indicators of potential payment integrity concerns

Closing Observation This month’s largest repayment was not driven by an obscure billing rule or a complex technical argument. It arose from fundamental questions about practitioner involvement, clinical input, documentation and whether the requirements of the item billed had actually been met. Across Australia, the United States and the United Kingdom, the lesson is remarkably consistent. Payment integrity failures rarely begin with sophisticated fraud. They begin when systems stop verifying that the service claimed is the service that was actually provided. The larger the scale, the larger the consequences.