PSR Director's Update for April 2018
In April 2018, 3 negotiated agreements came into effect and 1 final determination became effective.
A. Director’s Section 92 agreements effective in April 2018
The following agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) were ratified:
- An agreement with a general practitioner. This practitioner’s rendering of Medicare Benefits Schedule (MBS) items 23, 36, 721, 723, 732, 5020, 66596 and 66833 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $130,000 and will be reprimanded by the Director.
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 701, 2713, 2717, 18234, 18236, 31230, 31240, 31260, 31270, 45000, 45200, 45203, 45206, 45207, 45451 and 45617 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $400,000, to be disqualified for 12 months from providing these items (except for MBS items 23, 31240, 31260 and 31270) and will be reprimanded by the Director.
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 5020 and 5040 and prescribing of Pharmaceutical Benefits Scheme items 8254K and 8319W was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing or prescribing these items. The practitioner agreed to repay $200,000 and will be reprimanded by the Director.
B. PSR Committees' final determinations effective in April 2018
One final determination became effective in April 2018.
PSR Committee No. 988
This psychiatrist was directed to be reprimanded and counselled by the Director and to repay $545,755.74 to the Commonwealth. These directions followed from a final report of a PSR Committee which concluded the practitioner engaged in inappropriate practice for services that he rendered as MBS items 304, 322, 324 and 326 during the review period.
MBS items 304, 322, 324 and 326 are consultation items. The Committee found that for more than half of the reviewed services billed as these items, no notes were created to support the billing of a consultation item. On occasions where there were notes, they were handwritten and often illegible.
MBS item 304
MBS item 304 is a consultation item for attendances lasting 30 to 45 minutes at consulting rooms (that is, for outpatients). The Committee found that, for this item, the illegibility of the practitioner’s records alone would often have made it difficult for another practitioner to take over management of one of his patients. Even with the benefit of him explaining to the Committee what his notes said, it was difficult to discern from the records what clinical input had been provided or what decision-making had occurred, such as why a particular course of treatment had or had not been followed. Clinical impressions or conclusions (for example, ‘as usual’, ‘bright mood’ or ‘stable’) were often recorded without explanation.
The illegibility of the records was such that it was often difficult to discern what a patient’s symptoms were, whether there was any risk of self-harm, the results of any mental state examination (if conducted) and any broader patient management plan. This was also hampered by the practitioner not keeping an up to date health summary for each patient.
Additionally, the practitioner’s records regularly included the same or substantially similar entries each time a patient presented and it was difficult to discern the last time that a detailed patient review was included in the records.
In addition to the systematic adverse findings about the practitioner’s recordkeeping for MBS item 304, the Committee made additional findings about his clinical input and compliance with the MBS requirements.
Some of these adverse findings related to the practitioner’s prescribing. These included that the practitioner unacceptably failed to monitor patients’ liver function in connection with his prescribing of Tegretol. In some cases, patients’ medication dosages were increased without explanation. In other cases, the practitioner prescribed different antipsychotic medications with potential adverse side effects and long term health issues. The practitioner often did not arrange follow up appointments to monitor patient’s medication usage. It was not evident that the practitioner provided clear clinical guidance to patients or set parameters for when patients would take varying dosages. In other cases, medications were prescribed without adequate clinical indication.
In some cases, the practitioner did not provide sufficient clinical input in connection with patients taking ongoing medications. This included one patient who presented with an elevated pulse rate. The patient’s blood pressure was not taken even though they were taking tranylcypromine, which is a monoamine oxidase inhibitor that can result in hypertensive crisis for a patient if they do not adhere to relevant dietary requirements. Necessary steps were not taken (such as a blood pressure test) to rule out a medical emergency for the patient.
The Committee also found that the practitioner failed to comply with regulatory requirements. The reasons for this included that the evidence did not indicate the consultations lasted the minimum time listed in the item descriptors (30 minutes) as the records did not support consultations of this duration (if consultations were even provided).
MBS item 322, 324 and 326
These MBS items are for psychiatric consultations provided to inpatients. For almost every inpatient, the practitioner billed MBS item 322, 324 or 326 for every day they were hospitalised. The practitioner often failed to create a consultation note on each occasion an inpatient item was billed. For example, for one patient, there were no entries on seven consecutive days, when on each day a Medicare service was billed for that patient by the practitioner.
For cases where records were created by the practitioner, the Committee found that the practitioner’s notes were unacceptably inadequate. The Committee found that the sparse detail that was recorded was inadequate in failing to document pertinent clinical information including the results of mental state examinations, risk assessments and clear management plans. As a result of that limited detail, the Committee found it difficult to accept that the minimum time to bill the item was required. The assessment of safety issues was very sparse, admission notes lacked important clinical information, and there was no or infrequent follow-up of issues raised by nursing staff about safety or acute symptomatology. The practitioner often recorded his impression of the patient’s progress as ‘okay’ or ‘all good’, which did not usefully explain what his clinical reasoning and management plan might have been. Other clinical conclusions were recorded without any explanation about how they were formed.
The Committee also found that that there was no obvious connection between the practitioner’s notes and other notes made around the same time by hospital staff. This indicated he might not have paid much attention to the circumstances of patients as reported to him by other staff members. Information relating to how patients had progressed during their hospital admissions was often not recorded.
C. Federal Court
The decision in the judicial review application first mentioned in September 2017 remains reserved.
D. Referrals to the major non-compliance (fraud) division
No matters were referred to the major non-compliance (fraud) division in April 2018.
E. Referrals to AHPRA
One matter was referred to AHPRA in April 2018.