Australia Snapshot August was a much busier month for the Professional Services Review, with 12 section 92 agreements coming into effect. Collectively, the practitioners agreed to repay $2,768,251.85 to the Commonwealth. Ten of the 12 matters involved general practitioners and two involved gastroenterologists and hepatologists. Repayments ranged from $9,000 to $450,000, with numerous practitioners also receiving reprimands, counselling and disqualifications from specified MBS items. The same payment integrity problems continue to appear: minimum times not met, services lacking sufficient clinical input, inadequate records, inappropriate prescribing, inappropriate co-billing and very high service volumes. But one case deserves particular attention. Last month we wrote about retrospective alteration of clinical records. It has happened again. This time, a practitioner amended or created patient records after receiving a statutory notice requiring those records to be produced. August PSR cases Case 1 - records created or amended after a statutory notice A general practitioner agreed to repay $318,000, was reprimanded and counselled, and was disqualified from specified MBS items for 12 months. The case involved GP attendances, health assessments and chronic disease management services. The familiar problems were there: minimum-time requirements were not always met, clinical records were inadequate and contemporaneous documentation was lacking. But buried among those findings was something considerably more concerning. PSR found that, in some cases, the practitioner had amended or created patient records after a statutory notice to produce had been issued. We highlighted almost exactly this problem last month. In September PIM, we reported on a UK dentist convicted of fraud involving 1,037 NHS claims. Part of the criminal case against her involved altering treatment dates in patient records to increase claims. Our integrity signal then was: Retrospective alteration of records is not merely a documentation problem. One month later, here we are again in Australia. A statutory notice has been issued. The practitioner knows their conduct is under scrutiny. And records are subsequently amended or created. Yet the Australian outcome is administrative: repayment, reprimand, counselling and temporary disqualification from specified Medicare items. The contrast with overseas healthcare fraud enforcement is becoming increasingly difficult to ignore. High-volume telephone billing Three matters involved prescribed patterns of services. One GP rendered 30 or more relevant phone services on each of 28 days during the review period. Another did so on 27 days. A third practitioner rendered 30 or more relevant phone services on 40 days. In each case, PSR concluded that exceptional circumstances did not exist to explain the pattern. The problems did not end with volume. PSR also identified services where minimum times were not met, clinically relevant tasks were not completed and records did not adequately explain what occurred. One practitioner prescribed restricted medications following very brief telephone or telehealth attendances, including in circumstances involving mental-health histories, substance-use concerns, potential drug-seeking behaviour and significant polypharmacy risk. Another prescribed antibiotics when they were not clinically indicated, failed adequately to follow up test results and repeatedly applied cryotherapy to the same anatomical area where PSR considered repeated treatment was not clinically required. That practitioner agreed to repay $350,000 and was disqualified from providing the relevant skin-procedure item for three years. The 80-services-a-day rule appears again Another GP rendered 80 or more relevant services on each of 27 days during the review period. Again, PSR found no exceptional circumstances. The practitioner also failed to meet minimum-time requirements for some services, provided some item 36 services that were not clinically relevant, and was not eligible to render some telephone and video services because they were not the patient's usual medical practitioner. The outcome was a $450,000 repayment, reprimand, counselling and a 12-month disqualification from a video attendance item. This was the largest repayment of the month. Specialists, procedures and the consultation that wasn't separate Two gastroenterologists and hepatologists also came under scrutiny. One agreed to repay $95,000 after concerns involving specialist attendances and telehealth services. Among the problems identified were consultations billed where the patient's referral was for a procedure only, consultation items co-billed with procedures without sufficient clinical input to establish a genuinely separate consultation, failure to meet minimum times, and consultations billed for standard aftercare relating to the procedure. PSR also questioned future colonoscopies that were not supported by the patient's histology results or previous procedures. The second gastroenterologist and hepatologist agreed to repay $29,000. Again, PSR identified consultation items co-billed with procedural services where there was insufficient clinical input to establish a separate consultation. There were also concerns about inadequate correspondence with referring practitioners and services that were not clinically indicated, including use as part of a routine screening program. This is a recurring payment integrity problem worth remembering: Being in the room with the patient does not create a separately billable consultation. Where a consultation is billed alongside a procedure, there must actually be a separate, clinically relevant consultation that satisfies the requirements of the item. And routine aftercare does not magically become another consultation simply because an attendance item is added to the claim. Nurse time is not doctor time Another GP agreed to repay $280,000. Among the findings was a deceptively simple problem with time. The practitioner included time spent by a practice nurse with the patient as part of the attendance time used to satisfy the requirements of the doctor's MBS service. No. Where an MBS item requires the medical practitioner to spend a specified minimum time providing the service, time spent by somebody else cannot simply be added to the clock. The same case also involved inadequately individualised GP management plans and team care arrangements, failures to perform all clinically relevant tasks and co-billed items whose requirements had not been independently satisfied. It is another reminder that co-billing two items means satisfying two sets of requirements. Two item numbers do not turn one service into two. Dominant themes across August

• Record integrity is becoming more serious. Poor records are one thing. Creating or amending records after receiving a statutory notice to produce them is something else entirely.
• Time means the practitioner's time. Minimum-duration requirements cannot be satisfied with services that were too short, and practitioner attendance time cannot simply include time spent with another health professional.
• Volume remains a powerful integrity signal. Thirty or more phone services a day and 80 or more services a day continue to trigger prescribed-pattern scrutiny.
• Clinical relevance matters independently of time. Sitting with a patient for the required number of minutes is not enough. The service itself must satisfy the relevant MBS requirements and involve appropriate clinical input.
• A procedure does not automatically generate a consultation. Specialist attendance items billed alongside procedures require a genuinely separate service. Standard procedural aftercare is not a new consultation.
• Prescribing is a payment integrity issue. August's cases included antibiotics prescribed without clinical indication, restricted PBS medicines prescribed outside their restrictions, brief telehealth prescribing and potentially dangerous polypharmacy.
• Templates remain dangerous. Pre-populated plans and records must be sufficiently individualised to demonstrate what actually happened with the particular patient.
• Co-billing means separate services. Each item claimed must independently satisfy its requirements. One clinical interaction cannot simply be divided into multiple billable services because several item numbers are available.

The bigger question There is something uncomfortable about seeing retrospective record alteration appear again only one month after we highlighted exactly the same issue. Australian payment integrity enforcement continues to describe conduct primarily through the language of inappropriate practice, inadequate records and failure to meet item requirements. Other countries increasingly use a different vocabulary when records are deliberately manipulated in connection with healthcare payments. They call it fraud. Whether Australia is drawing that line in the right place is a question we think deserves much closer scrutiny. Payment Integrity Around the World United States - Medicare billed for surgeries that allegedly never happened On 29 September, the US Department of Justice filed a False Claims Act lawsuit against a Texas physician alleging that he billed Medicare almost US$500,000 for surgical neurostimulator electrode implantations that were not actually performed. These are complex surgical procedures that require an operating room and attract Medicare payments of thousands of dollars. But according to the government's allegations, that isn't what patients received. Instead, non-physician practitioners and even non-clinical staff allegedly used inexpensive electro-acupuncture devices during brief office visits. Small electrode wires were inserted into the patient's skin and the devices attached behind their ears with adhesive. The government alleges that the physician nevertheless billed Medicare for the much more expensive surgical procedure. The allegations have not yet been determined by a court. Integrity signal: Payment integrity starts with one deceptively simple question: what service was actually provided? A claim can contain a perfectly valid billing code and still be false if that isn't the service the patient received. You can read the full case here - US Department of Justice. United States - US$22.5 million Medicare Advantage settlement over diagnosis codes On 30 September, Independence Blue Cross agreed to pay US$22.5 million to resolve allegations that it submitted, or failed to withdraw, inaccurate and untruthful diagnosis codes that increased the payments it received from Medicare. Medicare Advantage payments are risk-adjusted. In simple terms, plans generally receive more money for beneficiaries expected to require more healthcare. That makes diagnosis coding a payment integrity issue. The US government alleged that Independence Blue Cross conducted chart reviews that identified additional diagnoses that could increase payments. But there was another side to those reviews. They also identified previously reported diagnoses that the medical records did not substantiate. The government alleged that the insurer used the chart-review results when they supported additional payments but failed to delete diagnosis codes when the same process showed Medicare had overpaid. A former employee brought the whistleblower action and will receive US$3.825 million from the settlement. The settlement resolves allegations only and there has been no determination of liability. Integrity signal: An integrity control cannot operate in only one direction. If a review is used to identify underpayments, the same review must also be acted upon when it identifies overpayments. You can read the full case here - US Department of Justice. United States - US$20.5 million for allegedly identifying an overpayment and then keeping it This case takes the overpayment issue one step further. On 30 September, Signal Diagnostics agreed to pay US$20.5 million to settle allegations that it knowingly retained federal healthcare payments to which it was not entitled. During the COVID-19 pandemic, a US government program reimbursed providers for testing and treatment of uninsured patients. Signal subsequently conducted an internal audit and identified claims it had submitted to the uninsured program for people who actually had health insurance. According to the government, Signal didn't merely discover that there might have been a problem. It continued its audit, calculated the amount it had been overpaid, and then allegedly failed to return the money. The settlement resolves allegations only and there has been no determination of liability. Integrity signal: Finding an overpayment is only half the job. Once an organisation knows public money has been paid incorrectly, what it does next becomes an integrity issue in its own right. You can read the full case here - US Department of Justice. United States - false or unsupported diagnoses allegedly increased Medicare payments On 6 October, AIDS Healthcare Foundation agreed to pay US$1.44 million to resolve allegations involving false or unsupported diagnosis codes submitted through the Medicare Advantage program. Again, the issue was risk adjustment. The organisation's own coders conducted chart reviews and identified diagnosis codes that potentially lacked support in the medical record. Those codes were placed on internal “Delete Research” spreadsheets for further investigation. But according to the US government, many of the inaccurate or unsupported diagnoses were not deleted until 2024 or 2025 — well after the organisation had been alerted to the potential problem and, in some cases, after the government investigation had begun. The government also alleged that HIV diagnosis codes were submitted in some cases without the required documentation from a face-to-face visit. The organisation has agreed to pay US$1.44 million to settle the allegations. There has been no determination of liability. Integrity signal: Identifying a questionable diagnosis internally does not resolve the payment integrity risk. Once an organisation has information suggesting a claim may be unsupported, failure to investigate and correct it can itself have consequences. You can read the full case here - US Department of Justice. France - prescriptions allegedly written to maximise reimbursement, not treat the patient This is one of the most extraordinary cases this month. On 28 September, France's national Gendarmerie announced the dismantling of an alleged organised healthcare fraud scheme involving 22 individuals and 15 companies, including ophthalmologists, ophthalmology centres and opticians. Investigators allege that some opticians referred customers to complicit ophthalmologists who sometimes issued prescriptions without even examining the patient. More importantly, authorities allege that the prescriptions were based not on the patient's actual medical needs, but on what would generate the maximum reimbursement from health insurers and the French social security system. Patients allegedly received the glasses they genuinely needed while more expensive and unnecessary products appeared within the reimbursement arrangements. Some opticians reportedly acknowledged that more than half their turnover depended on the alleged scheme. Authorities estimate approximately €12 million a year may have been diverted since 2023 in the scheme under investigation. Investigators also suspect similar practices may be considerably more widespread in the Paris region. The accused are due to face court in 2027, so these allegations have not yet been determined. Integrity signal: This turns the normal relationship between medicine and payment completely upside down. The clinical decision should determine the claim. The reimbursement opportunity should never determine the clinical decision. You can read the full case here - French National Gendarmerie. Netherlands - follow the money On 29 September, the Netherlands Labour Authority announced the arrest of a woman suspected of laundering healthcare funds through her healthcare business. Authorities allege that the business received more than €2 million in healthcare funds during 2023 and 2024, but that around half — more than €1 million — does not appear to have been spent on care or labour-related costs. Investigators suspect some of the money was instead withdrawn as cash, transferred into private accounts, characterised as loans and used to purchase a car and other luxury goods. And the way this case began is particularly interesting. It wasn't initially detected through clinical records or healthcare claims analysis. The investigation followed a report from the Netherlands' Financial Intelligence Unit after unusual transactions in the business's bank accounts were identified as suspicious. The matter remains under investigation and the allegations have not been determined. Integrity signal: Payment integrity shouldn't necessarily stop when the claim is paid. Sometimes the most revealing control is the simplest one of all: Follow the money. You can read the full case here - Netherlands Labour Authority. The message from around the world is consistent. Billing for services that were not provided, manipulating records or diagnoses to increase payments and/or engineering clinical decisions around reimbursement is called fraud. It is investigated by fraud squads, police and financial intelligence agencies, prosecuted through the courts and, where proved, can result in prison. Australia remains the outlier. Deliberate deception for financial gain is called fraud and it belongs in law enforcement.