Case descriptions
Decision to take no further action
Dr AE
General practitioner/General surgeon
Victoria
Dr AE practiced in a rural area of need where he was the only general surgeon in the local district. He was also on call for the accident and emergency department at the local hospital.
Medicare Australia was concerned that Dr AE’s rendered services, daily servicing, initiation of pathology, diagnostic imaging and prescribing under the PBS may have involved inappropriate practice. During the review period Dr AE provided 17,488 services to 6331 patients for total benefits of $665,241.65. Dr AE was above the 99th percentile for total services rendered when compared to his peers.
The Director reviewed a large sample of Dr AE’s medical records and considered there were no concerns about MBS item 23, 104,12 31325, 31270, 30061, 31200, 31255, 47369 services.13 The Director was concerned, however, that Dr E may not have met the MBS item descriptor for MBS item 1.14
According to Medicare statistics Dr AE performed complicated procedures (MBS items 3200315 and 3151816) only once during the review period. The Director and a surgical consultant agreed that in performing a minimal number of these procedures, Dr AE might not have maintained the minimum level of competence required.
The Director met with Dr AE at his surgery to discuss Medicare Australia’s concerns. Dr AE advised that he had worked in his current practice for 26 years and that he worked seven days a week starting at 5.30 am and finishing at 10.30 pm with no breaks. Dr AE said he had trouble turning patients away and had always worked long hours. Dr AE explained that he was called upon to do most operations in the hospital and, after nightly rounds, he attended patients in the accident and emergency department.
While visiting with Dr AE the Director was invited to speak to hospital staff about Dr AE’s provision of MBS item 1 services. After these discussions and after consulting the Department of Health and Ageing the Director was satisfied that Dr AE had not engaged in inappropriate practice in providing MBS item 1 services during the review period.
Dr AE’s practice manager provided the Director with a copy of the hospital audit report detailing the total operations Dr AE had performed over the past three months. The Director was satisfied that Dr AE was fully competent to perform the major surgery he provided during the review period. Many of the operations Dr AE performed were for public patients and had therefore not appeared on Medicare Australia’s statistics. This circumstance had given the false impression that Dr AE did not undertake sufficient numbers of procedures to remain competent.
The Director considered that Dr AE was a hard working and competent practitioner, held in high esteem by his colleagues, staff and the local community.
At a further meeting with the Director, Dr AE outlined his plans for his future retirement from Australian practice. The Director considered it appropriate to resolve this matter under section 91 of the Health Insurance Act 1973 and took no further action.
- 12 MBS item 104 is a specialist consultation
- 13 MBS items 30061, 31325, 31270, 31200, 31255 and 47369 are minor surgical items
- 14 MBS item 1 is an emergency after hours attendance at a place other than consulting rooms
- 15 MBS item 32003 is for resection of the large intestine
- 16 MBS item 31518 is a total mastectomy