PSR Director’s Update for July 2017

16 August 2017

 

In July 2017, 3 negotiated agreements and 2 final determinations came into effect.

A. Director’s Section 92 agreements effective in July 2017

The following agreements entered into by the Director and persons under review (in accordance with s92 of the Act) were ratified:

  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 5020 and 11712 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering of these items. The practitioner agreed to repay $200,000, and will be reprimanded by the Director.
  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 721, 723, 732, 2715, 5020, 66716, 66833 and 16500 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering of these items. The practitioner agreed to repay $480,000, and will be reprimanded by the Director.
  • An agreement with a midwife. This practitioner’s rendering of MBS items 82110, 82115 and 82135 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering MBS items 82110 and 82115. The practitioner agreed to repay $15,000, and will be reprimanded by the Director.

B. PSR Committees’ final determinations effective in July 2017

PUR 912

On 14 June 2017, the Determining Authority made directions in respect of a medical practitioner who practises in general medicine ('other medical practitioner' category). The practitioner was directed to repay $328,714.25 to the Commonwealth and to receive a reprimand and counselling from the Director. These directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in rendering and initiating a proportion of services as MBS item 23, 65096, 69478 and 69481 services, and all MBS item 701, 723, 723, 732 and 2713 services during the 12-month review period. 

The nature of the conduct in respect of which the Committee found that the practitioner engaged in inappropriate practice was extensive. The Committee’s reasons included that the practitioner consistently failed to provide adequate clinical input, keep adequate records, and meet the MBS requirements for items that he billed. The Committee found that the practitioner’s understanding of MBS requirements was poor – for example, he could not differentiate between GP Management Plans (MBS item 721) and Team Care Arrangements (MBS item 723) in oral evidence.

The Committee’s findings included:

  • For health assessment (MBS item 701) services, the practitioner failed to record important clinically relevant information for all services that were examined, such as presenting complaints, patient histories, examination findings, management plans, diagnoses, and so on.
  • For chronic disease management (MBS item 721, 723 and 732) services, the documentation that the practitioner created for these services was of a very poor quality and contained inaccurate information. The practitioner used the same template across different patients for these services, without individualisation for each patient. 
  • For mental health care attendance (MBS item 2713) services, the practitioner was found to have failed to undertake tasks indicated in the item descriptor (such as taking a relevant history, identifying presenting problems, and so on), and also kept inadequate records and provided inadequate clinical input.
  • For pathology (MBS items 65096, 69478 and 69481) services, the Committee found, amongst other things, that a proportion of the services were initiated irrespective of clinical indications and in circumstances where adequate clinical input was not provided. 
  • In general, the practitioner failed to keep adequate records for many services reviewed – including because the entries were not adequate to explain the services that he billed or to enable another practitioner to undertake ongoing care of their patients. 

The Determining Authority’s repayment direction relates to MBS item 23, 701, 723, 723, 732 and 2713 services that the practitioner rendered during the review period. In making this repayment direction, the Determining Authority acknowledged that it may impose some financial hardship on the practitioner. However, this direction was considered appropriate having regard to the objects of the PSR scheme of protecting patients and protecting the Commonwealth from having to meet the cost of services provided in circumstances of inappropriate practice. The Determining Authority’s counselling direction gives the Director an opportunity to educate the practitioner about the necessary steps he must take to improve his compliance with the Medicare scheme in the future. 

PUR 914

On 14 June 2017, the Determining Authority made directions in respect of a general practitioner. The practitioner was directed to repay $342,512.15 to the Commonwealth and to receive a reprimand and counselling from the Director. These directions followed from a final report of a PSR Committee that concluded the practitioner engaged in inappropriate practice in rendering a prescribed pattern of services (or had breached the ‘80/20’ rule), for all services the practitioner rendered as Medicare Benefits Schedule items 721 and 723, and for some of the MBS item 66602 and 66596 services it examined.

In respect of the findings regarding the 80/20 rule, the Committee found that the practitioner provided 80 or more professional attendance services on each of 73 days during the 12-month review period. The practitioner raised a number of matters which were said to constitute ‘exceptional circumstances’ (which can operate as an exemption to the 80/20 rule for days on which they are found to exist). These matters included that the practitioner practised in a District of Workforce Shortage area and had a seasonal influx of patients during the 12-month review period.

The Committee did not find that exceptional circumstances existed. The Committee also found that, even if exceptional circumstances were found to exist, those circumstances did not causally ‘affect’ the practitioner’s rendering of services on the 73 days on which he was found to have rendered a prescribed pattern of services. As a result of the Committee’s findings, the Determining Authority directed that the practitioner repay $130,387.35 to the Commonwealth, which (after making deductions to avoid double counting MBS items 721 and 723) represents half of the benefits that were paid for professional attendance services on the relevant 73 days.

For chronic disease management items, the Committee found that the practitioner prepared GP management plans (MBS item 721) that were not comprehensive and did not disclose adequate clinical input specific to the patient. In relation to team care arrangements (MBS item 723), the Committee found that the services did not meet MBS requirements because the practitioner did not customise the templates they used and, where amendments to templates were made, those amendments did not create patient-specific tasks and goals. The Determining Authority directed repayment of all benefits that were paid for these items, or $137,723.60 for MBS item 721 services and $74,401.20 for MBS item 723 services.

The Committee also found that the practitioner initiated the sample of pathology services it examined (MBS items 66602 and 66596) without adequate supporting clinical indications. 

The Determining Authority found that the inappropriate practice which the practitioner engaged in was serious, which was an exacerbating factor in making its repayment directions. The Determining Authority also directed that the Director reprimand and counsel the practitioner, which gives the Director an opportunity to educate the practitioner about the necessary steps they must take to improve their compliance with the Medicare scheme in the future.

C. Federal Court  

No matters were determined by the Federal Court in July 2017.

D. Referrals to the major non-compliance (fraud) division

No matters were referred to the major non-compliance (fraud) division in July 2017.

E. Referrals to AHPRA

No matters were referred to AHPRA in July 2017.