PSR Annual Report 2006-07

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Report on performance

Final determinations made by the Determining Authority

Dr Ameen Ahmed Bham
General practitioner
Morley, Western Australia

Medicare Australia referred Dr Bham because he rendered high numbers of services, particularly MBS items 53, 54, 11506 and 11700.[6] Dr Bham claimed 17,103 total services during the review period.

The Director’s investigation revealed that for both MBS item 53 and 54 services, the clinical content of the services often appeared insufficient to have occupied the time allegedly spent with the patient. In other instances, Dr Bham raised additional accounts for what appeared to be normal aftercare where normal aftercare was included in the original procedural item.

Dr Bham was referred to a Committee and it found that in respect of MBS items 53 and 54 he engaged in inappropriate practice because he:

In respect to MBS item 11506 he:

In respect of MBS item 11700 he:

Committee questioning revealed Dr Bham had less than an elementary grasp of asthma management. Dr Bham admitted that he did not understand the readings generated by his respiratory function testing machine.

As the Committee was concerned that Dr Bham’s conduct in several areas of his practice had caused, was causing, or was likely to cause, a significant threat to the life or health of the patients under his care it made a statement to the Director who referred the matter to the Medical Board of Western Australia for further action.

The Determining Authority directed that Dr Bham:

Dr Mina Mounir Fahmy Moussa
General practitioner
Cloverdale, Western Australia

Medicare Australia referred Dr Moussa to the Director because it was concerned about his high volume of total rendered services; in particular, his rendering of MBS items 11700, 30061 and 42644.[7] Medicare Australia was also concerned about Dr Moussa’s level of prescribing tramadol hydrochloride.

The Director considered that the medical records he examined relating to MBS items 23 and 36[8] were brief and lacking in clinical detail. Frequently the records only contained diagnoses or presenting symptoms, and references to examination and management were brief. In some circumstances the entries consisted of only five or six words. Level C consultations were used for seemingly straightforward conditions, such as removal of sutures, minor respiratory infections and repeat prescriptions.

Dr Moussa was then referred to a Committee. The Committee found that 42 per cent of Dr Moussa’s item 36 services demonstrated inappropriate practice. Dr Moussa failed to take detailed histories or perform examinations of multiple systems. The medical records lacked essential clinical information, such as presenting complaints, patient histories, examinations, diagnoses and management plans.

Dr Moussa also failed to keep adequate records about his provision of ECGs and foreign body removal from the eye.

Dr Moussa inappropriately prescribed tramadol hydrochloride in a number of instances. Dr Moussa was not able to effectively monitor the quantity prescribed or the amount the patient was consuming. Prescriptions appeared to have been written on patient demand rather than on clinical indications.

The Determining Authority directed Dr Moussa be reprimanded and counselled, repay $18,415.43 in Medicare benefits and be fully disqualified from access to Medicare for three months.

Dr Peter Wayne Snodgrass
Chiropractor
Norwood, South Australia

Medicare Australia referred Dr Snodgrass because of concerns that he may have initiated diagnostic imaging services that may not have been necessary.

A Committee, consisting of three chiropractors, investigated Dr Snodgrass. The Committee reviewed a sample of medical records for patients for whom Dr Snodgrass initiated diagnostic imaging services. The Committee found that in 90 per cent of the examined services Dr Snodgrass failed to establish essential clinical criteria, such as evidence of trauma, deterioration of presenting condition or suspicion of new pathology. The Committee found that Dr Snodgrass’ failure to do this would be unacceptable to the general body of chiropractors.

For example, Dr Snodgrass initiated diagnostic imaging of the pelvic region for two female patients of child-bearing age and one teenager without adequate clinical justification.

Dr Snodgrass’ rationale for frequent testing was to monitor the progress of patients during a regime of regular chiropractic care. The Committee did not agree with Dr Snodgrass’ rationale and concluded that his conduct would be unacceptable to the general body of chiropractors.

The Determining Authority, which also included a chiropractor, directed that Dr Snodgrass be reprimanded and counselled by the Director or his nominee.

Dr Gias Swid
General practitioner
Fairfield, NSW

Medicare Australia was concerned that Dr Swid’s billing statistics may have indicated that he had engaged in inappropriate practice. During the review period Dr Swid rendered 19,769 services for a total benefit of $364,142.35. This was above the 99th percentile for all active medical practitioners in Australia. Medicare Australia was also concerned about Dr Swid’s prescribing of Cox-2 drugs under the PBS.

Following the Director’s review Dr Swid was referred to a Committee. The Committee examined a random sample of Dr Swid’s standard consultations (MBS item 53) and found that he had failed to provide an appropriate level of clinical input in that presenting complaints of patients were dealt with superficially, often with no attempt to investigate the underlying causes. The Committee also found that Dr Swid’s routine practice of asking patients if they felt hot instead of using a thermometer would be unacceptable to his peers.

The Committee described Dr Swid’s medical records as ‘rudimentary’, which reflected the lack of clinical input in his consultations. The Committee also found that Dr Swid recycled pages from other (older) patient records. This was confusing at best and had the potential to breach patient confidentiality and compromise the quality of care. Of the 36 records the Committee examined, 35 per cent were found to have involved significant inappropriate practice.

The Determining Authority directed that Dr Swid be reprimanded and counselled by the Director, repay $117,209.34 in Medicare benefits, and that he be fully disqualified from Medicare for six weeks.

Dr Patrick Glen McCabe
General practitioner
Southport, Queensland

Medicare Australia referred Dr McCabe because of his unusual ratio of long and prolonged consultations. During the review period Dr McCabe’s ratio of long (MBS item 54) to standard consultations (MBS item 53) was 1:0.55 when the average ratio for general practitioners was 1:4.17. The disparity with Dr McCabe’s peers was even more striking for prolonged (MBS item 57) to standard consultations; 1:1.97 compared to 1:52.75. Medicare Australia also had concerns about Dr McCabe’s services per patient and his initiation of pathology.

Following an investigation by the Director, Dr McCabe was referred to a Committee to consider his conduct. The Committee found that 90 per cent of Dr McCabe’s long consultations (MBS item 54) involved inappropriate practice.

Dr McCabe stated his patient base consisted of chronic disease and cancer patients. He offered treatment in molecular medicine, which he described as treatment focused on diet and supplements to ‘invigorate molecular function’. Dr McCabe also offered his patients immunotherapy described as consisting of ‘various ingredients which are known to be helpful in invigorating immune function…they consist of antioxidants, minerals and enzyme cofactors’. These treatments were administered by intravenous infusion.

The Committee found that Dr McCabe did not provide an appropriate level of clinical input and he failed to investigate presenting complaints and implement treatment. In three services patients reported shortness of breath; however Dr McCabe did not initiate investigation or treatment. Dr McCabe did not examine the abdomen, despite the patient having colon cancer. Dr McCabe explained his behaviour by saying ‘if he had some complaint about abdominal pain or something like that, I would have looked at it’. The Committee was alarmed that Dr McCabe relied on the patient to report any changes in such a significant condition.

Dr McCabe’s medical records were insufficient to contribute to the quality and continuity of patient care. Typically absent clinical information included presenting complaints, histories, examinations performed, findings, diagnoses, details of medications prescribed and management plans. Dr McCabe’s response, when the Committee challenged him about his records, was that he does ‘not interrupt interviews with patients to write notes’. Seven records reviewed revealed no notes of a consultation at all.

The Determining Authority directed that Dr McCabe be reprimanded and counselled by the Director and that he repay $25,391.20 in Medicare benefits. The Determining Authority further directed that Dr McCabe be fully disqualified from Medicare for three years. These sanctions represent the maximum that could be applied in Dr McCabe’s case.

Dr Nihal Jayantha Hewa
General practitioner
Flemington, Victoria

Medicare Australia referred Dr Hewa as his volume of MBS item 2 services was well above the 99th percentile. Dr Hewa rendered 950 MBS item 2[9] services during the review period. The 99th percentile for general practitioners at that time was 69.

The Director’s initial review suggested that the majority of the claims for MBS item 2 did not meet the MBS descriptor because the patients’ conditions did not appear to warrant immediate treatment.

Dr Hewa was referred to a Committee that found 18 per cent of MBS item 2 services he had rendered involved inappropriate practice. The Committee was of the opinion that Dr Hewa did not provide an appropriate level of clinical input to the services examined in that he:

The Determining Authority directed that Dr Hewa be reprimanded and counselled by the Director, that he repay $13,526.43 in Medicare benefits and be disqualified from the Medicare scheme for six months in relation to providing MBS item 2 services.

Dr Ashraf Edward Saddik
General practitioner
Coburg, Victoria

Medicare Australia referred Dr Saddik for a number of reasons. During the review period Dr Saddik rendered 10,493 services to 2070 patients for a total benefit of $356,851.65. Dr Saddik’s average of 5.07 services per patient was above the 93rd percentile of all general practitioners. Dr Saddik was above the 99th percentile for rendering enhanced primary care items 720, 724 and 740.[10] Medicare Australia was concerned that Dr Saddik’s use of chronic disease management items may have been inappropriate considering the profile of his patient base; 5.8 per cent of Dr Saddik’s patients were over 65 years.

Medicare Australia was also concerned about Dr Saddik’s rendering of skin sensitivity testing, skin excision items and initiation of pathology, in particular, his ordering of iron studies.

The Director’s review revealed that Dr Saddik may have ordered iron studies inappropriately in some circumstances. Similarly, the Director found that the majority of MBS items 720, 724 and 740 services did not satisfy the MBS item descriptor and did not appear to be medically necessary. As well, there did not appear to be clinical indications for 50 per cent of the MBS item 12003 (allergy skin testing) services examined.

The Director referred Dr Saddik to a Committee. The Committee found that all of MBS item 724 (review of a multidisciplinary community care plan) services involved inappropriate practice and 83 per cent of MBS item 740 services were inappropriate.

The Committee found that Dr Saddik’s care plans did not identify all care providers. In addition, the Committee heard evidence from a patient’s pharmacist who stated that despite being named in the care plans he had not received any documentation from Dr Saddik about the services in question. The Committee found that Dr Saddik did not provide an appropriate level of clinical input into the care plan reviews examined, and that he failed to review issues identified in the original care plans.

Dr Saddik’s failure to maintain adequate and legible records of care plan reviews would make it difficult for members of the care team, or another practitioner, to understand and effectively contribute to the care of these patients.

The Committee also found that Dr Saddik failed to satisfy the requirements for MBS item 740 services in that he failed to distribute copies of the case conference summaries to other participants and patients. Dr Saddik failed, on many occasions, to ensure sufficient participants attended and failed to obtain patient consent for case conferences to take place. The Committee found that some case conferences were not medically necessary.

The Determining Authority directed Dr Saddik be reprimanded and counselled by the Director, that he repay $3986.15 in Medicare benefits, and be disqualified from Medicare for three months in relation to all case conference items.

Dr Elizabeth Aileen Molnar
Psychiatrist
Brisbane, Queensland

Medicare Australia was concerned that Dr Molnar’s practice profile, which reflected many days with more than 10 hours consulting, may have involved inappropriate practice. During the review period Dr Molnar provided 3518 services to 327 patients for a total benefit of $352,667.80. Dr Molnar was above the 98th percentile for rendering MBS item 324,[11] above the 99th percentile for rendering MBS item 326[12] and above the 99th percentile for MBS item 328[13] when compared to all active consultant psychiatrists in Australia during the review period.

The Director engaged a consultant psychiatrist to review Dr Molnar’s records. The consultant’s view was that her clinical notes were ‘at best erratic, more frequently downright poor and occasionally entirely absent’. The consultant was also of the opinion that the only way to gain an understanding of the clinical content of her practice was for her to be investigated by a panel of her peers.

A Committee, including two consultant psychiatrists, was established. The Committee found that Dr Molnar’s conduct in connection with providing 60 per cent of MBS item 306[14] services examined would be unacceptable to the general body of consultant psychiatrists.

Dr Molnar’s records lacked essential clinical information such as current medications, side effects, dosage and reasons for alteration, mental state examinations and management plans. Additionally, hospital discharge records and referral documentation were often absent from the records. In defence of her notes Dr Molnar submitted that she had been advised by a senior professional colleague to ‘make very extensive notes or you make very short notes’. In the Committee’s opinion, the general body of consultant psychiatrists would expect that medical records should contain objective clinical details of mental state examinations, medication reviews, details of professional care provided and management plans.

The Determining Authority considered the inappropriate practice disclosed in the Committee’s report to be of a very serious nature and directed that Dr Molnar be reprimanded and counselled, repay $98,215.17 in Medicare benefits and that she be disqualified from Medicare for six months in relation to providing psychiatric MBS items.

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