Case descriptions
Agreement entered into between Director and person under review
Dr A
Medical practitioner
New South Wales
Dr A is a medical practitioner working exclusively in a skin cancer clinic. Dr A has a postgraduate in dermatology and undertakes annual training with the Skin Cancer Society.
Dr A also has a Masters of Medicine.
Medicare Australia referred Dr A to PSR due to his level of EPC items, in particular MBS items 721 and 72522 and his itemisation of skin excision services. Medicare Australia’s data suggested that Dr A was not managing chronic and complex medical conditions; therefore, he may have rendered EPC items that were not clinically relevant. Medicare Australia’s data also showed that an unusually high proportion (84 per cent) of lesions Dr A had excised were itemised as over 10 mm in diameter, with as many lesions of more than 20 mm as there were lesions less than 10 mm. Consequently, Dr A’s medical records relating to skin excision items were examined.
Dr A’s clinical notes suggested that the tumours were considerably smaller than those claimed, or the diagnosis did not meet MBS requirements. Even allowing for artifactual shrinkage the pathology indicated that the lesion was initially smaller than the item claimed would indicate.
The Director was also concerned that Dr A appeared to use skin flaps in inappropriate circumstances where wound closure could have been effected by direct closure.
Dr A’s rendering of EPC items was also considered inappropriate. As Dr A worked exclusively in skin cancer medicine the management plans, as recorded, would not have added any value to the patients’ care. These plans covered items that should have been provided in the framework of a normal consultation.
As part of the review the Director met with Dr A at his practice location. Dr A practises in a low socioeconomic area and bulk bills all patients.
Given Dr A’s involvement with the local and surrounding communities’ health services and his willingness to acknowledge his inappropriate practice, the Director decided to resolve this matter through a negotiated agreement. Dr A agreed to be reprimanded by the Director and to repay $27,412 in Medicare benefits.
This case illustrates that waiting for the pathology report before billing the patient would resolve some of the issues. Dr A’s inappropriate use of GP Management Plans should remind practitioners that conditions that could be easily managed in the course of normal general practice do not warrant a management plan.
- 22 MBS item 725 is a care plan review