PSR Annual Report 2008-09

Previous | Next

3. Case descriptions

Negotiated agreements

Section 92 of the Health Insurance Act 1973 refers to cases where the Director has made an agreement with the person under review.

Over the last four years a review has resulted in a negotiated agreement in approximately 50 per cent of cases.

Cases resolved by a section 92 agreement have been finalised on average in less than eight months. The practitioner’s name is not published. The essential element of a section 92 agreement is the practitioner’s acknowledgement that they have practised inappropriately in relation to provision of certain services and/or that they have prescribed PBS items inappropriately.

The range of actions available under a section 92 agreement includes reprimand, repayment of benefits and disqualification from Medicare for up to three years. The terms of a section 92 agreement are a matter of negotiation and agreement between the Director and the practitioner under review.

While a section 92 agreement is a speedier and more cost effective option than a referral to a PSR Committee it is only considered under certain conditions. A practitioner must

acknowledge they have practised inappropriately and they must be able to demonstrate they have significantly altered their practice so the inappropriate behaviour is unlikely to be repeated.

A section 92 agreement will not be considered if there has been flagrant abuse of Medicare or if there has been poor clinical practice likely to lead to a low standard of patient care. A practitioner who has little insight into his or her own behaviour will not be offered a section 92 agreement.

In 2008–09, 33 negotiated agreements were ratified. Table 7 summarises the issues Medicare Australia raised, the issues PSR identified, and the actions that formed part of these negotiated agreements.

The examples discussed below illustrate the types of cases that have been resolved by section 92 agreements.

Table 7: Negotiated agreements, Issues Medicare Australia raised, inappropriate practice found, and actions taken, 2008–09
Practitioner Medicare Australia concerns Outcomes of negotiated agreements
Consultation items Aged care consultation Care plans 721, 723, 725, 2710 Domiciliary medication management review Optometrical consultations Prescribing antibiotics Prescribing narcotics Prescribing anti inflammatories Therapeutic procedure Pathology services Diagnostic imaging Inappropriate practice Agreed action
Consultation items Chronic disease management Cardiac investigation items Procedural items Radiology Pathology Prescribing Repayment of benefits ($)* Full disqualification (weeks) Partial disqualification (months)
A X X X 5,000
B X X X 18,000 6
C X X X X 4,070
D X X X R
E X X R
F# X X 178,994 36
G X X 4,300
H X X X X 1,937 4
I X X X X 74,975 2
J X X X X X 77,000
K X X X X X X X 47,000 6
L X X X X 30,000
M X X X X X X 12,441 12
N X X 20,000
O X X X X 50,956 3
P X X X X X 44,000 3
Q X X X 40,000 6
R X X X X X 70,000 6
S X X X X X X 100,000 9
T X X X 10,000 2
U X X X 5,000 2
V X X X X 13,400 6
W# X X X 4,000
X# X X X 21,419
Y X X X X X X X 50,000 4
Z X X X X X X 65,000 6
AA X X 20,000 3
AB X X X X X 7,500
AC X X X X X X 13,880
AD X X X 50,000 6
AE# X X X X X X 80,000 24
AF X X X R
AG X X X 84,000 12

Notes:

Dr F
General practitioner

Dr F worked in a clinic specialising in investigating cardiovascular disease in unreferred patients. Medicare Australia asked the Director to review Dr F’s provision of services during the review period. Medicare Australia was concerned that Dr F’s provision of MBS item 11712,2 11612,3 and 116114 services was at the 100th percentile compared to all other medical practitioners in Australia. Dr F’s total Medicare billing for the period was $672,317.10.

Dr F’s medical records were examined; all disclosed evidence of inappropriate practice. Dr F had not taken an adequate history nor conducted an appropriate physical examination for the presenting complaint of the patient. In addition he had performed investigations that were not clinically necessary for the care of the patient. In particular he had performed measurements of ankle and brachial blood pressure in patients without a history suggestive of lower limb ischemia and had not carried out an appropriate physical examination of the lower limbs. Dr F had also performed venous plethysmography in patients for whom there was no clinical indication present. It appeared, from the medical records, that investigations Dr F carried out bore little relationship to the clinical needs of the patient.

After 15 months of working for the centre Dr F returned to general practice. He now practises in a clinic employing 15 general practitioners.

Having considered Dr F’s submission, his acknowledgment of inappropriate practice during the review period and his return to general practice, the Director believed that Dr F’s

case may be one in which it was appropriate to enter into an agreement pursuant to section 92 of the Health Insurance Act 1973.

Dr F signed a section 92 agreement in which he acknowledged having practised inappropriately in providing MBS item 11604,5 11610,6 11611, 11612 and 11712 services where no clinical indications for these types of investigations existed. He also acknowledged having kept medical records that were deficient in essential clinical information.

Dr F agreed to repay to the Commonwealth $178,994 and be disqualified from providing the above MBS item services for three years.

This case illustrates that any form of clinical investigation that attracts Medicare benefits must be clinically relevant and in the interests of the patient. The remuneration a practitioner receives should never be a consideration.

Mr W
Optometrist

Medicare Australia referred Mr W because it was concerned about his provision of MBS item 109407 services. During the review period Mr W had rendered MBS item 10940 145 times for a total benefit of $7,237.60.

The Director engaged an optometrist in full-time practice as a consultant. The consultant examined Mr W’s patient records and concluded that almost half the patients for whom Mr W had used computerised perimetry had conditions that did not meet the required MBS criteria.

Mr W had used this test on patients who had a family history of glaucoma as their only risk factor. This is not sufficient to justify using perimetry under the MBS. Additional risk factors, such as raised intra-ocular pressure above 22 mm Hg or suspicious cupping of the optic disc, must be present.

In his submission Mr W acknowledged that he had incorrectly interpreted the MBS item descriptor and since becoming aware of his error had altered the way he determines eligibility for claiming for computerised perimetry.

The Director was of the opinion that a section 92 agreement was appropriate to resolve this matter. Mr W was officially reprimanded by the Director and agreed to repay $4,000 in Medicare benefits.

This case should put all optometrists on notice that although computerised perimetry is a relatively new MBS item, care must be exercised in its use. The criteria for providing this item are set out in the MBS and must be adhered to.

Dr X
Consultant physician (gastroenterologist)

Medicare Australia was concerned at the frequency with which Dr X charged MBS item 304738 services in association with MBS item 304879 services. Dr X had received $557,451.65 in total Medicare benefits that included $51,985.25 for providing MBS item 30473 services in conjunction with MBS item 30487 services.

On examination of Dr X’s medical records the Director was concerned that Dr X had charged a consultation item on the same day as he had carried out a gastroscopy. As Dr X had determined at a previous consultation that gastroscopy was indicated, no clinical justification existed for billing a further consultation item at the time of the gastroscopy.

In addition, Dr X had on many occasions also carried out a small bowel intubation and biopsy without any relevant clinical indication to do so, while also claiming for an oesophagoscopy, gastroscopy and duodenoscopy. Small bowel intubation and biopsy has a limited set of indications and should not be done as a routine extension of examining the oesophagus, stomach and duodenum.

During the course of the review the Director counselled Dr X about his provision of MBS item 30473 and 30487 services and his use of consultation items with procedures. Dr X made an undertaking to change his practice.

In Dr X’s case it was not necessary to convene a PSR Committee and the matter was concluded by Dr X entering into a section 92 agreement in which he acknowledged his inappropriate practice in charging a consultation item with procedural items where no clinical need for a separate consultation existed. He acknowledged inappropriate practice in rendering MBS item 30487 services where there was no clinical necessity to do so. Dr X agreed to repay $21,419 in Medicare benefits.

This case should be a reminder to all practitioners who undertake procedural work. It is inappropriate to charge a consultation item at the same time as a procedure unless there is a clinical necessity for that consultation separate from the performance of the procedure. The time taken for the procedure is included in the MBS benefit. MBS benefits are not paid for saying hello to a patient on an operating theatre trolley.

Dr AE
General practitioner

Medicare Australia referred Dr AE because it was concerned about the high volume of services she rendered, in particular MBS item 90010 services. During the review period Dr AE had rendered 14,208 services to 2,076 patients. Dr AE was at or above the 98th percentile for services per patient and above the 99th percentile (29 services) for her rendering of MBS item 900 services (108 services).

The Director decided to undertake an extensive examination of Dr AE’s provision of services, examining the medical records in relation to MBS items 23,11 36,12 44,13 721,14 900 and 271015 as well as her prescription of amoxycillin. After examining her records the Director had no concerns about Dr AE’s prescribing of amoxycillin.

The Director was concerned, however, with Dr AE’s provision of consultation services and initially considered she had a significant case to answer. Dr AE’s recording of patient histories and examinations was lacking in essential elements that would allow another practitioner to take over the care of a patient. This was particularly relevant in a number of patients who presented with serious illness and Dr AE failed to record vital areas of history and examination in the medical record. Dr AE’s clinical notes recorded for the longer consultations, such as MBS items 36 and 44, were scant and failed to indicate that the service provided met the relevant MBS item descriptor.

Examination of Dr AE’s medical records in relation to MBS item 900 services confirmed Medicare Australia’s concerns that this item was provided incorrectly. There was no recorded evidence of the patient’s visit or any recorded discussion with the patient about the results of a Domiciliary Medication Management Review. Use of this MBS item did not appear to have had any beneficial effect on patient care.

Dr AE’s use of MBS item 2710 was also found to be inappropriate. The records lacked evidence of clinical input in documenting a mental health plan and commonly no needs assessment, no goal setting and no management plan were recorded. Medical records examined relating to patients who presented with depression contained no evidence of a suicide risk assessment. This was of considerable concern to the Director.

In a detailed submission Dr AE acknowledged her clinical records were inadequate and reflective of inappropriate practice. She stated her intention to attend a workshop held by her medical defence organisation focusing on risk management, in particular medical notes and practitioners’ obligations under law. Dr AE further recognised that she is not a good time manager and recently attended several workshops on decision making and dealing with difficult patients. Changes to other aspects of her practice should also adequately address the Director’s concerns and improve Dr AE’s practice management. Dr AE’s submission importantly revealed she had considerable insight into the reasons her practice had come under scrutiny.

The Director considered a section 92 agreement an appropriate resolution to this matter. Dr AE agreed to be reprimanded by the Director, repay $80,000 and be disqualified from providing MBS item 900 for two years.

Practitioners are reminded that clinical records serve not only as an aide memoire for the practitioner who creates them but also as forming an integral part of good medical care. Clinical notes are regularly forwarded to a new practitioner when a patient moves house and it is incumbent on all practitioners to keep records that another practitioner could use and safely continue a patient’s care. The days of half a line of illegible scrawl on a 5”x7” card must be relegated to history.

Previous | Next