All practitioners referred to the Medicare watchdog who went through to the committee stage were found to have participated in inappropriate practice.
For the third year running, 100% of PSR committee reports have resulted in a finding of inappropriate practice against the practitioner under review, resulting in 17 reprimands, five cases of full MBS disqualification and repayment orders of up to $1.9 million.
The Professional Services Review only investigates practitioners referred to it by Medicare – although the two agencies are technically separate – for suspected inappropriate billing or fraud.
According to its 2024-25 annual report, which was released this week, it received 116 requests for investigation.
This is only slightly higher than usual, with the average over the past five years being about 101 requests per year.
Of these 116 referrals, 10 were for practitioners who had been before the PSR at least one other time.
Seven of the 10 had previously admitted fault or been subject to a final determination; in other words, they had faced the PSR before and lost, or at the very least they had not escaped unscathed.
There were also at least 39 referrals for practitioners who broke the 30/20 telehealth rule or the 80/20 overservicing rule.
For the 115 cases that the PSR did finalise, there were just seven where it elected to take no further action.
For all intents and purposes, this is the same as the PSR deciding that the practitioner has done nothing wrong or that the practitioner could prove genuine exceptional circumstances.
The remaining 108 practitioners proceeded on to either a negotiated agreement a committee of peers.
If a decision for no further action is analogous to charges being dismissed, a negotiated agreement is more akin to a guilty plea and the committee stage is something like entering a ‘not guilty’ plea and going to a jury trial.
The 90 practitioners who opted for a negotiated agreement – i.e. acknowledged that they may have engaged in inappropriate practice – repaid a collective $19.9 million.
This works out to an average of $220,000 per practitioner.
Half were partially disqualified from billing the MBS and one was fully disqualified.
The majority – 76 practitioners out of 90 – were also ordered to receive counselling on appropriate billing practices.
That leaves 18 other practitioners whose final determinations came into effect in the 2024-25 financial year.
All practitioners bar one received a formal reprimand, while 12 were partially disqualified from the MBS and a further five were completely disqualified from the MBS.
These 18 practitioners collectively repaid $7.4 million, or an average of $411,000 per practitioner – close to double the average repayment for practitioners who admitted fault.
This cohort includes practitioners who may have completed the committee stage in a previous financial year.
Of the 84 committee reports delivered over the last five financial years, just one has made a finding of no inappropriate practice.
This year was no different to the previous two, with 16 of the 16 finalised committee reports finding that the practitioner under review had engaged in inappropriate practice.
In most cases, PSR director Dr Antonio Di Dio wrote, the PSR was concerned that practitioners had not kept adequate and contemporaneous records, did not provide sufficient clinical input into the services provided, performed services that were not clinically indicated or did not meet the MBS or PBS requirements for each service.
“In 2024–25 commonly reviewed services continued to include those relating to in-person and telephone attendances, chronic disease management, health assessments and mental health services as well as services involving the prescribing of opioid medications and antibiotics,” the PSR annual report said.
“There continued to be an increase in the number of telehealth and telephone services items reviewed, reflecting an uptake in the use of these items by the profession.
“The common areas for concern in these services mirrored those for in-person attendances, being a lack of recorded information to reflect the clinical input provided.
“The same record keeping requirements apply to telehealth and telephone services as for in-person attendances.”
There are three requirements for record keeping. It must provide sufficient clinical information to explain the services, be completed at the time of the service or as soon as practicable after and be sufficiently comprehensible to another practitioner.
“The Director and Associate Directors frequently observed brief records that did not include important clinical information such as a relevant patient history, any examination results or the intended management plan,” the annual report read.
“At times, practitioners relied on templates that had not been adequately individualised to the patient’s circumstances.
“The Director and Associate Directors were concerned that these deficiencies would not enable another practitioner to be able to take over care of the patient in reliance on the record.”
There were also three cases of potential fraud referred back to the chief executive of Medicare in the 2024-25 financial year.
