Case descriptions
Agreement entered into between Director and person under review
Dr K
Medical practitioner
New South Wales
Medicare Australia previously referred Dr K to PSR in 2000 over concerns about high volume of daily services and total high volume of rendered services. The outcome of that review was a negotiated agreement ratified by the Determining Authority in 2001.
Dr K was later registered for the MedicarePlus Program entitling him to render vocationally recognised general practitioner (VRGP) consultation items.
Dr K came to Medicare Australia’s attention again in 2004 in relation to prescribing of Cox-2 inhibitor drugs. Medicare Australia asked PSR to review Dr K’s provision of services in relation to chronic disease management services. During the review period Dr K rendered 227 item 721, an increase of 363.27 per cent from the previous year and 239 item 723, an increase of 670.97 per cent from the previous year.
Dr K’s patient demographic revealed he now had a younger population base and his previously large elderly population of patients had declined.
Samples of Dr K’s medical records were reviewed; they were difficult to read, contained no health summary sheets and contained limited clinical detail. Records examined relating to MBS item 36 noted simple presentations that would not have had the complexity required to meet the MBS criteria. The chronic disease management services did not fulfil the item descriptors and in many cases were considered not medically necessary for the patient’s care.
Records examined in relation to item 2710 contained no recorded evidence of a risk assessment or mental state exam.
The Director met with Dr K to discuss his review. Dr K indicated that he had misunderstood the MBS criteria in relation to some items. Dr K stated that an adviser of his local Division had told him that patients should have a care plan if they had a chronic condition without qualification. The Director discussed with Dr K the appropriateness of providing care plans.
Dr K agreed that he had practised inappropriately. He agreed to be reprimanded by the Director and to repay $40,000 in Medicare benefits. Once the Determining Authority had ratified the agreement it became the second adverse finding for Dr K under the PSR Scheme. This mandated a referral to the Chairperson of the Medicare Participation Review Committees.