Case descriptions
Agreement entered into between Director and person under review
Dr J
General practitioner
New South Wales
Medicare Australia requested a review of Dr J’s provision of services due to concerns over his daily servicing, rendered MBS item 1150635 and 11700 services and EPC services.
Dr J’s patient numbers were in the 80th percentile and benefits were in the 99th percentile; he was in the 99th percentile for rendering item 11506 and in the 98th percentile for rendering item 11700. During the review period Dr J rendered twice as many EPC services as the previous year.
The medical records reviewed contained a number of inadequacies that raised concerns. Records examined in relation to MBS item 2710 contained no evidence of an assessment of suicide risk being undertaken, and there was no evidence of an outcome tool used, as required by MBS. The Director considered approximately 40 per cent of MBS item 721 services were not medically necessary. Finally, there was no evidence of a meaningful review or changes to patient needs and goals in the records examined for item 725.
The records examined in relation to item 11506 contained no evidence as to the clinical relevance of this test being undertaken. The result of the tests did not appear to alter the treatment of any patient, nor add any benefit to the patients’ care. The records examined in relation to MBS item 11700 contained little clinical justification for this test being performed.
The Director met with Dr J to discuss the review. Dr J is a solo practitioner with a special interest in mental health. He had been practising for 25 years and is the only practitioner in his area providing home visits. His patients were well known to him. He acknowledged that he had not included details in his written notes of his provision of cognitive behaviour or relaxation therapy.
Dr J stated, in a written submission to the Director, that he has begun a comprehensive review of his files to address deficiencies. Dr J further advised that as a result of the Director’s review he would be liaising with his local Division of General Practice and the Royal Australian College of General Practitioners to ensure selection criteria and documentation requirements are always followed for GP management items. He also undertook to seek appropriate assistance to improve his documentation and record keeping.
It was the Director’s opinion that the seriousness of the identified concerns was such that a negotiated agreement would be appropriate.
Dr J agreed to be reprimanded by the Director, repay $16,800 in Medicare benefits, and be disqualified from items 11700 and 11506 for six months.
- 35 MBS item 11506 is measurement of respiratory function