Case descriptions
Agreement entered into between Director and person under review
Dr S
General practitioner
New South Wales
Medicare Australia was concerned that Dr S’s rendered services, daily services and EPC services may have involved inappropriate practice. Medicare Australia had similar concerns in a previous request in 2002. A section 92 agreement that the Determining Authority ratified in 2002 had resolved the previous matter.
Dr S was in the 99th percentile for rendered services; there was an increase in the number of days when 80 to 89 services were rendered. Dr S was in the 97th percentile for EPC services.
Upon review of Dr S’s records the Director found that half his notes relating to item 36 services were brief and lacked clinical detail. The presentations were simple and would not have the complexity level to justify an item 36 claim. In most cases his GP Management Plans were found not medically necessary. Dr S’s prescribing of simvastatin did not satisfy the qualifying criteria for use of this medication under the PBS.
The Director met with Dr S to discuss the review. Dr S said he had not initiated the prescribing of simvastatin, as patients had come to him after being prescribed the drug by either a specialist or another general practitioner; the Director accepted Dr S’s explanation.
The Director decided that the most appropriate action was to enter into a negotiated agreement. Dr S agreed to be reprimanded by the Director, to repay $67,810 in Medicare benefits and to be disqualified from provision of items 36 and 721 for two months.
As this was Dr S’s second adverse finding under the PSR Scheme, he was referred to the Chairperson of the Medicare Participation Review Committees for review of his continuation in the Medicare arrangements.