PSR Director's Update for August 2017

1 September 2017

 

In August 2017, 6 negotiated agreements and 1 final determination came into effect.

A. Director’s Section 92 agreements effective in August 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 24, 36 and 597 and prescribing of Pharmaceutical Benefits Scheme (PBS) items 1215Y, 2089Y, 2622B and 3162K were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering all of these items except for PBS item 8757X, in relation to which the Director had no concerns. The practitioner agreed to repay $70,000, and will be reprimanded by the Director.
  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 44, 721, 723, 732, 2713, 2715, 2717, 10997 and 30006 and prescribing of PBS items 2622B and 3162K, were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering these items. The practitioner agreed to repay $350,000 and will be reprimanded by the Director.
  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 36, 715, 2701 and 5040 were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering these items. The practitioner agreed to repay $190,000 and will be reprimanded by the Director.
  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 705, 707, 721, 723, 56223, 56507 and 66833 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering these items. The practitioner agreed to repay $500,000, will be disqualified for 12 months in respect of rendering MBS items 721 and 723, and will be disqualified for 24 months in respect of MBS items 705, 707 and 715.  The practitioner will also be reprimanded by the Director.
  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 705, 715, 721, 723, 732, 2521, 2525, 2712, 2713, 2715, 2717, 63551 and 66716 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering all of these items, except for MBS items 63551 and 66716 in relation to which the Director had no concerns. The practitioner agreed to repay $360,000, will be disqualified for 12 months in respect of rendering MBS items 705, 721, 723, 732, 2715 and 2717 and will be reprimanded by the Director.
  • An agreement with a general practitioner. This practitioner’s rendering of MBS items 36, 44, 2521, 2712, 2713, 5040 and 73805 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering MBS items 2521, 2712, 2713, 5040 and 73805. The director had no concerns in respect of the other items reviewed. The practitioner agreed to repay $25,000.

B. PSR Committees’ final determinations effective in August 2017

PUR 921

On 23 June 2017, the Determining Authority made directions in respect of a general practitioner. The practitioner was directed to repay $176,987.12 to the Commonwealth, to receive a reprimand and counselling from the Director, and was disqualified from rendering MBS items 701, 723, 732 and 2715 services for three months. These directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice for all services he rendered as MBS items 701, 723, 732, 2715, 30029, 30035 and 47915 during the 12-month review period. The Committee also found that he had breached the 80/20 rule, with no exceptional circumstances affecting that breach.

In relation to MBS item 701 (health assessments), the Committee found that the practitioner did not record sufficient detail in connection with health assessment examinations. The Committee concluded he did not undertake those examinations or did so perfunctorily. The item descriptor required the practitioner to, among other things, collect relevant information, perform a basic examination, initiate interventions and provide preventative health care advice. Some or all of these tasks were not adequately completed or documented by the practitioner. It was of particular concern that the practitioner did not record that he had collected relevant information in connection with this item, which is fundamental to the purpose of this item.

In relation to Team Care Arrangments (TCAs - MBS item 723), the Committee found, among other things, that the documents that the practitioner had prepared for this item did not record the treatment and services goals for patients’ relevant conditions or the treatment and services collaborating providers were expected to provide to patients. TCAs were generic and not customised, and included limited or no patient-specific detail, to the extent that another practitioner, relying on the practitioner’s TCAs, would not be able to effectively undertake ongoing care of his patients.

In relation to reviews of TCAs (MBS item 732), the Committee found that the practitioner did not comply with the MBS requirements of this item. There was also insufficient detail in the practitioner’s reviews to enable another practitioner to effectively undertake ongoing care of his patients.

In relation to all MBS item 47915 (ingrown nail resection) services reviewed, the Committee found that the practitioner did not surgically remove nail beds and ungula folds (as required by the MBS item descriptor) but instead ablated nail beds by curettage. The practitioner’s notes for these services also did not contain sufficient detail to explain the nature of each surgical procedure.

For MBS item 2715 (mental health care plans), the Committee found that the overall quality and recordkeeping associated with these plans was poor. It found that plans did not record some or all of the following:

  • an adequate history of the condition(s) for which the plans were prepared;
  • substance use history;
  • findings of mental state assessments; and
  • patient’s medication usage.

The Committee found that the practitioner’s plans did not include specific treatment goals nor provide for crisis or relapse intervention, and the overall quality of his plans and clinical recordkeeping in association with this item was poor.

In relation to MBS item 30035 (repair of wounds on face or neck involving deeper tissue), the item descriptor stipulates that wound closure services rendered as this item must involve deeper tissue. The Committee found that the practitioner did not record the depth or length of wounds, nor clinical observations meaningfully indicating whether the wound repair involved deeper tissue. The suture material that the practitioner used was not suitable for insertion for deep wound closure. Examination findings (such as whether wounds were oozing, whether there was subcutaneous venous bleeding, whether wounds had dehisced, whether wounds were gaping and an anatomical description of wounds) were not recorded. Basic histories, including the causes of wounds, were not recorded.

Similar findings were made in respect of MBS item 30029 (repair of wounds other than on face or neck involving deeper tissue). The practitioner did not keep notes that documented the anatomical location of injuries, a description of wounds that were repaired (including their depth), and the cause of wounds. The clinical reasoning for suturing was also not adequately documented in each case.

The practitioner agreed with the Committee during the course of the hearing that he had not complied with basic MBS and recordkeeping requirements in respect of each item.

The practitioner also rendered 80 or more professional attendance services on each of 30 days during the review period, thereby breaching the 80/20 rule. The practitioner gave oral evidence that indicated that he was not aware of the requirements of the 80/20 rule. Specifically, he thought that the rule referred to the number of patients seen per day, not the number of professional attendance services rendered.

The Committee did not accept that exceptional circumstances existed on any of the relevant 30 days. The practitioner contended that he was pressured into working additional hours and that he had to cover for absent practitioners. This was found to be an ordinary incident of general practice and in any case, this submission was made at a general level and without reference to any particular day(s) on which the 80/20 rule was breached. The Committee also found that the practitioner’s circumstances did not satisfy any of the exceptional circumstances prescribed by the regulations.

The Determining Authority’s repayment direction of $176,987.12 represents the whole of the benefits that were paid for MBS items 701, 723, 732, 2715, 30029, 30035 and 47915 and 50% of the benefits paid for services the practitioner rendered on days on which he breached the 80/20 rule. While these directions involved some financial imposition on the practitioner, the Determining Authority considered that they were commensurate with the extent of the inappropriate practice found by the Committee.

C. Federal Court 

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

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

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

E. Referrals to AHPRA

One matter was referred to AHPRA in August 2017 for noncompliance with professional standards.