Australia Snapshot July was a quieter month for the Professional Services Review, with only two adverse PSR outcomes, but both reinforce recurring payment integrity risks around minimum service times, chronic disease management and the integrity of clinical records. In total, the two practitioners were required to repay $390,000 to the Commonwealth, with disqualifications extending to 18 months. One section 92 agreement came into effect in July. One final Committee determination came into effect on 24 July. Both matters involved general practitioners. The most serious outcome involved a GP ordered to repay $260,000, representing approximately 100% of the Medicare benefits paid for the individual services found to involve inappropriate practice. We also revisit an important June case involving a psychiatrist and TMS services after PSR subsequently removed substantive information from the published outcome. July PSR cases Case 1 – a GP A general practitioner repaid $130,000, received a reprimand and was disqualified from specified MBS items for three months. The practitioner exceeded 99% of their peers claiming chronic disease management and telephone services, including MBS items 721, 723 and 91891. As usual, the PSR identified inadequate and non-contemporaneous records, discrepancies concerning dates and how services were provided, chronic disease plans that were insufficiently comprehensive, inadequate evidence of collaboration with other healthcare providers, patients who did not appear eligible for chronic disease management services and telephone attendances that did not always meet minimum-time requirements. Case 2 - another GP. This time a committee hearing. The second case was considerably more serious. A general practitioner was ordered to repay $260,000, was reprimanded and counselled and received multiple MBS item disqualifications ranging from six to 18 months. The Committee's findings extended across standard GP attendances, long consultations, health assessments, chronic disease management, after-hours services, residential aged-care services and telephone attendances. For many services, the practitioner did not provide sufficient clinical input to justify the item claimed or did not meet the minimum time requirement. Several services billed as after-hours services did not occur, or did not substantially occur, during the after-hours period. For some health assessments, the practitioner did not attend the patient on the date of service. There were also problems with co-billed nurse services. In some instances, no separate nurse service had been provided; in others, the nurse service was not consistent with an existing GPMP or TCA. In any other country, much of this would be called fraud and prosecuted accordingly. One finding stands out. In relation to services involving MBS items 44, 721, 5040, 5060 and 91891, the practitioner produced non-contemporaneous records that had been created or altered after the PSR review process had commenced. Once again, in other countries falsification of records for financial gain is fraud, a crime. But not here. Dominant themes across July

• Record integrity: inadequate records featured as always.
• Time means time: minimum-duration requirements again featured across all attendance services.
• Clinical input: billing a time-based item requires sufficient clinical input as well as satisfaction of the minimum time.
• CDM remains high risk: generic or incomplete plans, ineligible patients and inadequate collaboration with other providers continue to attract scrutiny.
• Prepopulated templates are high risk: auto-populated information does not demonstrate that the practitioner collected, considered or used that information in managing the patient. You must sufficiently particularise for every patient.
• Co-billing requires separate services: nurse services cannot simply be added to a claim where no legitimate separate nurse service occurred.
• After-hours means after-hours: several services failed because they did not occur, or did not substantially occur, during the required after-hours period. In our view – fraud.
• Record integrity extends beyond record adequacy: retrospectively creating or altering records is a serious offence anywhere in the world. Though we don’t prosecute it seriously here.

You can read the full report here. A PSR TRANSPARENCY PROBLEM We also need to return to a June PSR case because something important has changed since it was first published. The case involved a psychiatrist and transcranial magnetic stimulation (TMS) services. When PSR originally published the outcome, it told us exactly which services were involved and how much money was being repaid: MBS items 14216, 14217, 14219 and 14220. Repayment: $418,000. Those details have now been removed from PSR's published outcome. So we are putting them back into the public record here. The case involved serious concerns about TMS billing, including splitting the required content of a therapeutic psychiatric service across two separately billed attendances; billing a service where the patient's response to prior treatment had not been established using a validated major depressive disorder tool; inadequate follow-up and monitoring, or billing those steps as additional services; and billing attendance services under the psychiatrist's provider number when the patient had actually been attended by another practitioner. PSR's current version now says only that the practitioner agreed to repay “a portion of the Medicare benefits paid for the therapeutic psychiatric services under review” and was disqualified from “4 relevant MBS item services”. That is significantly less information than PSR originally gave the public. We do not know why the outcome was subsequently altered. But in our view, removing this information is not in the public interest. The practitioner was already anonymous. Publishing the item numbers and repayment amount did not identify them. It told the public what Medicare services were involved and the financial scale of the inappropriate practice. That information matters to practitioners, billing teams, health funds and compliance professionals trying to identify areas of payment integrity risk. PSR outcomes are an important source of compliance intelligence for the Australian health sector. Removing substantive information after publication makes them less useful and makes it harder to identify enforcement patterns over time. If a regulator retrospectively changes a published enforcement outcome, there should be a transparent record of what changed, when it changed and why. Payment integrity requires transparency from practitioners. It should require transparency from regulators too. Payment Integrity Around the World United States – US$541.5 million Medicare Advantage settlement The Villages Health System agreed to pay US$541.5 million to resolve allegations that false diagnosis codes were submitted to increase payments received under the Medicare Advantage program. The allegations covered conduct between 2020 and 2024. The diagnosis codes were allegedly unsupported by the medical record or based on amendments that were not initiated by the treating provider, were not timely, or were not approved by the treating provider. The organisation self-disclosed the invalid diagnoses, took remedial action and cooperated with the investigation, which the U.S. Government took into account when resolving the matter. Integrity signal: Diagnosis coding is payment integrity. Where reimbursement is risk-adjusted, unsupported diagnoses can directly increase the amount of public money paid. You can read the full report here. United Kingdom – Dentist convicted over 1,037 fraudulent NHS claims Former NHS dentist Fariba Shameli was convicted of fraud involving 1,037 claims worth £92,511. The conduct included claiming for dental treatment that was never performed, submitting NHS claims where patients had actually paid privately, and claiming for work performed by trainee dentists. Particularly relevant to this month's Australian PSR outcome, the prosecution also established that the dentist altered treatment dates in patient records to increase claims in a particular financial year. The case was investigated by the NHS Counter Fraud Authority and prosecuted by the Crown Prosecution Service. Integrity signal: Retrospective alteration of records is not merely a documentation problem. In this case, alteration of treatment dates formed part of a criminal fraud prosecution. You can read the full report here. Canada – Police investigation expands into alleged hospital fraud The Ontario Provincial Police joined an investigation into alleged fraud at London Health Sciences Centre, with police citing the complexity of the investigation and the specialised resources required. The investigation began after the hospital reported concerns to London Police in 2024. The hospital has previously said an investigation identified alleged fraudulent activity occurring between 2013 and 2024, and it has filed three civil lawsuits seeking a combined C$80 million. The allegations have not been proven in court. Integrity signal: Major healthcare integrity failures can become governance failures. Where alleged misconduct persists for years, scrutiny inevitably extends beyond individual transactions to organisational systems, oversight and accountability. You can read the full report here. New Zealand – $1 million hospital fraud exposed by a patient query An employee at Christchurch Hospital responsible for invoicing and collecting revenue from patients who were ineligible for free healthcare defrauded the hospital of NZ$1 million over six years. The employee manipulated hospital systems and redirected 475 patient payments into accounts she controlled. The scheme included offering unauthorised cash discounts, creating fake invoices containing her own bank details, entering incorrect patient information to make patients appear eligible for free healthcare and using a manual accounting process to make debts effectively disappear from the hospital system. And importantly, the fraud was ultimately uncovered because a patient questioned an invoice for treatment they had already paid for. The hospital investigated, discovered that the bank account shown on the patient's documentation was not its account, conducted an internal audit and referred the matter to New Zealand's Serious Fraud Office. The employee was prosecuted and sentenced to three years imprisonment. Integrity signal: Patients are an important payment integrity control. Sometimes the person who spots that something is wrong is not an auditor, regulator or algorithm. It is the patient who looks at the bill and asks a question. You can read the full report here. Global Takeaways

• Record integrity means preserving the original record. Once a record is changed to support a claim or after scrutiny has commenced, the matter becomes much more serious.
• Time remains one of the simplest and strongest payment integrity controls. Australian PSR cases continue to identify services where minimum durations were not met or where insufficient clinical input was provided to support the item claimed.
• Patients are part of the payment integrity system. The New Zealand hospital fraud was discovered because a patient questioned an invoice. We see evidence of this in Australia every day. Patients accessing their Medicare records often find the fiction that exists therein.
• Governance matters. The Canadian investigation demonstrates that where alleged healthcare misconduct is systemic or prolonged, payment integrity cannot be confined to the person processing an individual claim. Organisational oversight and accountability also matter.
• Transparency is itself an integrity issue. Regulators expect healthcare practitioners to maintain accurate, transparent and contemporaneous records. The same principle should apply to published enforcement outcomes. Material information should not quietly disappear from the public record.

Payment integrity depends on being able to follow the evidence. Who provided the service? What happened? How long did it take? What was documented? What was billed? Who paid? And where did the money go? Those questions remain remarkably consistent across healthcare systems around the world.