Case descriptions
Agreement entered into between Director and person under review
Dr E
General practitioner
Queensland
Medicare Australia referred Dr E for a variety of concerns including his provision of rendered services, services per patient, initiation of pathology, itemisation of skin lesion excisions, consultations in the after care period, and prescribing of lipid lowering drugs and drugs of potential dependence.
Medicare Australia’s statistics showed that Dr E rendered 12,513 services to 2123 patients for total Medicare benefits of $412,407.65. Dr E was above the 97th percentile for total services rendered when compared to his peers. Dr E initiated 6888 pathology services for 884 patients. Dr E was above the 97th percentile for skin excision items.
The drug Dr E most frequently prescribed during the review period was pravastatin sodium; he was above the 99th percentile in issuing 491 prescriptions for this medication.
Dr E’s medical records were examined. Records relating to MBS item 36 services lacked sufficient detail to justify the claim. Although the consultations did occasionally deal with more than one problem, conditions treated were often straightforward and should have been billed using a different MBS item.
The Director found insufficient evidence in the medical record to justify a claim for MBS item 30192.26 It appeared from the notes that Dr E was claiming this item for removal of warts or removal of less than the required 10 or more lesions. The records dealing with excision of tumours suggested that even allowing for shrinkage the histopathology suggested that the tumours were considerably smaller than the MBS requirements.
The Director’s review of Dr E’s medical records revealed evidence of excessive pathology ordering, as the investigations initiated had no role in the diagnosis or management of patients’ symptoms.
The records revealed that Dr E did not meet the PBS criteria for prescribing pravastatin. Dr E readily provided multiple prescriptions of temazepam and oxazepam but there was no evidence that patients had been advised of the drugs’ habituating properties.
After a meeting with the Director where these concerns were discussed Dr E made a written submission. Dr E acknowledged that his medical records were lacking in clinical detail and he had begun to address this concern. Dr E’s submission supported his claim that he was addressing the excessive initiation of pathologies that arose from his aggressive and proactive approach to the significant lifestyle problems his patients suffered. He further outlined the steps he would be implementing to address the Director’s concerns.
Dr E is a solo practitioner who operates in a depressed area with patients from a low socioeconomic demographic who have few health care alternatives. Dr E welcomed the Director’s review as an opportunity to reflect upon his manner of practice and gain insight into the matters that were of concern.
The Director considered that this matter could appropriately be resolved by a negotiated agreement. Dr E agreed to be reprimanded by the Director, repay $60,000 in Medicare benefits and to be disqualified from providing MBS item 31210, 31215, 31285 and 30192 services27 for 12 months.
- 26 MBS item 30192 is premalignant skin lesions, 10 or more lesions treated by non-surgical means
- 27 MBS items 31210, 31215, 31285 and 30192 relate to excision of skin lesions