Professional Services Review Annual Report 2004–05

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2. Report on performance

Reasons for requests and referrals

Commission requests for review

The reasons the Commission requests a review of the provision of services by a practitioner generally fall within select and distinctive categories. As the Commission only has access to claims data and any information elicited by a medical adviser during a visit, the categories are limited to the results of statistical interrogation. Requests generally fall into one or more of the following categories:

Table 8—Types of concerns in Commission requests

2004–05 2003–04
Prescribed pattern of services 2 0
High volume of services 6 16
High Medicare Benefits Schedule level C and/or D services 1 6
High services per patient 0 8
High ordering of pathology and diagnostic imaging 0 12
High Pharmaceutical Benefits Scheme prescribing 4 17
Other 6 18

Note: some referrals contained more than one of the above concerns.

Committee referrals

When the Director makes a decision to review, he has the power to obtain patient records and other relevant documents that are examined by appropriately qualified and experienced practitioners. This gives a greater insight into the particular practitioner’s behaviour than was available to the Commission.

Consequently, issues become apparent following a review and may form part of the following reasons for referral to a committee:

Table 9—Types of services referred to committees

2004–05 2003–04
Prescribed pattern of services 1 2
Standard consultations 1 3
Long consultations 3 1
Prolonged consultations 2 1
Other Medicare Benefits Schedule items 4 7
Pharmaceutical Benefits Scheme prescribing 1 2
Pathology and/or Diagnostic Imaging 1 0

Note: some referrals contained more than one type of service.

Table 10—Reasons for referral to committees

2004–05 2003–04
Inadequate clinical input 6 4
Inadequate medical records 10 3
Services not medically necessary 8 4
Medicare Benefits Schedule not satisfied 8 4

Note: all referrals contained more than one reason.

Other types of concerns

There are three other areas of concern that can become apparent during an investigation or during a committee process. These are:

A discussion of the different types of concerns in Commission referrals, reasons for referral to committees and other types of concerns follows.

Prescribed pattern of services

Following a 1999 review of the scheme by the Australian Medical Association (AMA), the Commission, the Department of Health and Ageing and PSR4 legislative changes were made to include a method of examining the conduct of practitioners who have high volumes of services. The legislation came into effect for services rendered after 1 January 2000, and the first wave of these referrals was received in 2002–03.

In a significant departure from other types of referrals, a practitioner who performs a nominated number of services in a particular period is deemed by the legislation to have practiced inappropriately, unless they can provide evidence that exceptional circumstances existed. That is, the onus of proof is on the practitioner to demonstrate that he or she did not practice inappropriately.

Although a prescribed pattern of services can be applied to any medical specialty or type of service, so far the regulations5 only apply to general practitioners and other medical practitioners rendering professional attendances. Professional attendances are essentially consultations and do not include other services, such as procedural items.

The 1999 review committee, in consultation with the AMA Federal Council, the AMA Council of General Practice, the Royal Australian College of General Practitioners, the Rural Doctors’ Association of Australia and the Australian Divisions of General Practice, devised the formula of a combination of 80 or more professional attendances on 20 or more days in a 12-month period as indicative of inappropriate practice. In general, the profession accepted that practitioners providing such high volumes of services could not possibly be providing adequate clinical care for their patients.

The Director has limited power in respect of these referrals and although he can receive and consider submissions from the person under review, it is a committee that hears any claims of exceptional circumstances.

The regulations provide guidance—they declare exceptional circumstances to be:

‘an unusual occurrence causing an unusual level of need for professional attendances, and an absence of other medical services for patients of the person under review during the relevant period, having regard to the location of the practice and the characteristics of the patients.’

Of course, committees are not limited to these circumstances and are free to use their combined professional judgment in deciding what is an exceptional circumstance.

The review committee was firmly of the view that a high level of skill, competence and organisational arrangements were important for practitioners. But while these factors may have a great effect on a practitioner’s ability to provide 50, rather than 20, consultations regularly per day, the review committee indicated skill, competence and organisational arrangements would have little effect on the practitioner’s ability to provide 80 or more attendances per day.

The Federal Court has recently begun to give direction on interpreting the Act and the particular regulation. (See discussions on Oreb, Hatcher and Tisdall under Federal Court and Full Federal Court later in this chapter.)

High volume of services

It is important to appreciate that the prescribed pattern of services is not a ‘speed limit’ below which it is ‘safe’ and avoids investigation.

Apart from those practitioners referred under this concern, there is a small number who regularly provide a high number of services at or above the 99th percentile of approximately 14 200 services per annum. Rendering services at a level below that of a prescribed pattern of services does not prevent a practitioner being asked to justify their conduct.

The majority of general practitioners have great difficulty understanding how such large numbers of patients can be seen on a regular basis and still be provided with proper medical care. Proper medical care requires a range of activities by the treating practitioner, such as:

All of this takes time and no step can be omitted without jeopardising the patient’s health and/or increasing the risk of patient harm.

It may be financially rewarding for a practitioner to see high volumes of patients, but this style of practice generally only allows time for addressing the presenting symptom or complaint and is of little overall benefit to the patient. So far, committees have not accepted arguments that excessively high throughputs can be explained by claims of superior ability and organisation or vast experience.

High number of services per patient

Practitioners who provide, on average, a higher number of services per patient than their peers sometimes try to explain it by claiming to have a smaller and older (and ‘sicker’ with multiple pathology) patient base. However, committees have often found such behaviour to be the result of a practitioner acceding too easily to patient demands without due regard to the medical or clinical necessity for the frequency of service. These practitioners usually also have high unexplainable prescribing rates.

High prescribing of Pharmaceutical Benefits Scheme drugs

A high volume of prescribing under the Pharmaceutical Benefits Scheme often leads to a Commission referral. Many of these referrals involve prescribing of addictive pharmaceuticals, such as benzodiazepines, painkillers and narcotics. This year one referral expressed concern about prescribing. The Director was concerned the practitioner was prescribing drugs without naming the specific analgesic, dose or quantity (many entries merely had ‘pain killers’ recorded) and writing multiple scripts for the same medication on the same day. It seems, from evidence committees gathered, that on occasions, high prescribing is again a result of the practitioner acceding to patient demand or as a way for the practitioner to end the consultation.

Inadequate medical records

Ten of the Director’s referrals (other than referrals concerning prescribed pattern of services) to committees contained a concern that the practitioner had failed to keep adequate and contemporaneous medical records.

This is more than 90 per cent of referrals. This must be of major concern to the profession, particularly because of the effort it has exerted in educating practitioners in recent times.

In addition, in every one of the 26 effective determinations and 11 negotiated agreements concluded during the year, there was a conclusion that each practitioner had failed to keep adequate and contemporaneous health records.

A good record is an important element to justify the service initiated or rendered. In cases where the Director has dismissed a referral, or a committee has not made an adverse finding, the medical records have been such that they supported the practitioner’s conduct and claims. This highlights the importance of maintaining, not comprehensive or ‘gold standard’ records, but at the very least, adequate and contemporaneous medical records.

From 1 January 2000, Commonwealth legislation requires a committee, in consideration of a referral, to have regard to whether a practitioner has kept adequate and contemporaneous medical records. The committee is further required to take this into account when making decisions on whether the practitioner has engaged in inappropriate practice.

The Commonwealth’s requirement for patient records is broad and not as onerous as some state and territory legislation. For a record to be adequate, it must:

The extent that the practitioners referred for a prescribed pattern of services kept adequate or inadequate records is unknown because the Director does not need to order production of records in these cases. However, if previous experience with the records of other practitioners rendering high volumes of services is an indication, it is suspected that these practitioners’ records would also be significantly deficient.

Inadequate clinical input

Six referrals to committees this year concerned possible inadequate clinical input. During the Director’s review of the request, examination of medical records sometimes suggests the practitioner may not have provided adequate clinical input when treating patients. When there is little or no detail in the record, it is difficult to determine what service has been rendered.

The Act defines a professional service on which a Medicare benefit is paid, but leaves the decision of the clinical relevance of that service to what is generally accepted by practitioners’ peers as the appropriate treatment for patients.

Medicare Benefits Schedule item not satisfied

In eight cases referred to committees this year it appeared to the Director that the item of service the practitioner claimed may not have actually been provided at the appropriate level. In most cases, following review of the request and examination of patient records and practitioner submissions, the Director was of the view the practitioner may have claimed a Medicare Benefits Schedule item of greater value than the records or submissions demonstrated. Once again, when there is little or no detail in the record, it is difficult to determine what service has been rendered.

Common examples involved claiming a long, rather than a standard, consultation or claiming for suturing a deep wound, rather than a superficial wound. Although this could be considered a fraudulent claim, it would be difficult, if not impossible, to have such a finding upheld in an Australian court because of the difficulty, after a lapse of time, of proving intent to defraud.

The other common type of ‘error’ occurs where a practitioner regularly includes the time for procedural services as part of the overall time spent with the patient and hence itemises a longer consultation than actually took place. Some practitioners claim to be unaware that by billing a separate benefit for procedural services they are not entitled to add the time taken to the consultation component.

Services not medically necessary

This year eight referrals to committees contained the concern of services not being medically necessary. When a patient consults a practitioner for a particular problem the expectation is that they are going to be treated for that complaint, but it appears that some practitioners also perform services that are not clinically indicated and therefore not medically necessary.

This situation is often revealed upon review of medical records that show the patient’s presenting complaint and the resulting treatment. At times there appeared to be no correlation between the complaint and some of the treatment.

Particular services or types of services

Once the Director has completed a review (by examining patient records and practitioner submissions) of the broadly framed initial request from the Commission, it becomes more apparent where the concerns lie.

The Director is then able to focus the referral, for specific attention by a committee, on concerns within a particular Medicare Benefits Schedule item or items. Often this will lead to a referral of, for example, all Medicare Benefits Schedule item 36 or 44 services. Sometimes the referral will be for a particular procedural or diagnostic service. Questioning in the committee hearing often reveals there was no proper clinical indication for the procedure; the conclusion to be reached is that the indication for the procedure was only because the practitioner had access to the necessary equipment.

Professional isolation

Practitioners the Commission refers are often professionally isolated. They have little contact with professional colleagues and/or fail to keep their professional knowledge up-to-date. Others are manipulated by more senior practitioners or ‘employers’, or have deluded themselves. In the course of hearings, committees sometimes find impaired practitioners, mainly due to illness or substance abuse, and have referred these practitioners to the relevant Medical Board.

A number of practitioners who work as independent contractors or employees in medical centres have claimed that office staff are responsible for itemisation on documents for Medicare benefit. This defence has been accorded little weight because the practitioner alone is responsible for the accuracy of the information provided for the purposes of a Medicare claim and this responsibility cannot be delegated or abdicated.

Unusual medical practice

It is important for practitioners to remember that the PSR scheme applies to services rendered or initiated under the Medicare benefits arrangements and medications prescribed under the Pharmaceutical Benefits Scheme.

Within the legislation encompassing both schemes there are strict criteria for benefit eligibility.

Practitioners providing medicine that can be characterised as alternative or complementary need to be aware that, for their services to be eligible for a benefit, they must still meet the prescribed criteria.

The most important point is that the service must be clinically relevant. That is, the service must be generally accepted by the medical profession as being necessary for the appropriate treatment of the patient.

Alteration of documents

On a number of occasions, during both the initial review and at committee investigation, suspicion has been raised that the medical records produced have been altered subsequent to the notice ordering their production. This is an offence under Commonwealth legislation and arrangements are in place to enable prosecution of cases involving such fraudulent activity. State and territory medical boards are also concerned by such conduct and have significant penalties at their disposal.

3 A prescribed pattern of services also forms a reason for a referral from the Director to a committee.
4 The Report of the Review Committee of the Professional Review Scheme, March 1999, a copy is on the PSR web site at www.psr.gov.au.
5 Health Insurance (Professional Services Review) Amendment Regulations 1999 (No. 1)—SR1999 No. 346.

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