PSR referrals down, but 100% strike rate endures

The rate of new notifications to the watchdog has halved, but everyone who goes before a committee is found guilty of inappropriate practice.

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The Department of Health has eased its campaign to weed out doctors’ unusual billing or prescribing patterns in the past year, with new referrals to the Professional Services Review falling by about 60%.

The agency’s annual report revealed that the DoH had sent just 73 new requests in the 2020-21 financial year, a crash from 126 the previous year, which had been the second-busiest year in PSR history.

It also dipped below the agency’s previous five-year average of 99 new referrals per annum.

But unfortunately, GPs continue to be the most popular target for the PSR, making up more than half of all new referrals.

The decline in new referrals was attributed to the covid pandemic and the need to redeploy some of the DoH’s medical staff.

Any practitioners who come under the gaze of the PSR are initially monitored and referred by the DoH, who frequently audit for irregularities in engagement with the Medicare and Pharmaceutical Benefits schemes.

However, despite a much quieter year on the referral front, the PSR completed 105 cases and issued repayment orders to recoup $24.7 million for Medicare.

This was a modest reduction of 10% from the repayment orders issued in the 2019-20 financial year, which totalled $27.3 million.

Under the current operations of the PSR in section 91 of the Health Insurance Act (HIA), PSR Director Professor Julie Quinlivan is able to evaluate cases referred and act as the first judge and jury over whether further action is required on a case.
But of the 105 completed cases in the last financial year, only six were deemed to require “no further action”.

Not surprisingly, 85% of medical practitioners whose cases came under further PSR investigation decided to settle early by entering into a “negotiated agreement” with Professor Quinlivan, up slightly on the previous year.

Settling a PSR case at this initial phase with the Director often consists of the practitioner agreeing to repay a sum of money to Medicare and possibly being disqualified from providing certain MBS items for up to five years.

And by settling at this stage, a provision under section 92 of the HIA means the practitioner must also agree they have engaged in “inappropriate practice”.

Practitioners not wanting to admit to any wrongdoing or settle at the first stage of the PSR are referred by the Director to face a committee of their peers.

But the odds of being found innocent of having your name cleared at the committee stage have been proven to be zero for the seventh consecutive year.

In 2020-21, not a single person who went before a PSR committee received a finding of “no inappropriate practice”.

Professor Quinlivan also increased the number of practitioners she referred to AHPRA or the boards: 22 in 2020-21, up from a record high of 20 in the previous year.

For GPs, the most common items reviewed in PSR cases remained level B, C and D consultations in both face-to-face and telehealth settings.

Chronic disease management items, health assessments, ordering of pathology and prescribing were also popular items in 2020-21.

A small number of practitioners were identified as having engaged in obviously fraudulent Medicare billing.

In one case, a practitioner billed deceased patients for counselling and consultation services. In another, GP management plan services were recorded for patients who were not in Australia at the time of the service.

A third doctor had billed consults for patients who were discovered to be inpatients at a hospital in another town at the time of the service.

“These activities raise a concern over fraud and the matters are referred back to the Department of Health to decide if additional intervention is indicated, other than consideration of inappropriate practice,” the PSR said.