PSR Director's Update for August 2018

9 October 2018

 

Due to the nature of negotiated agreements and secrecy limitations imposed by the legislative scheme, no practitioners who have entered into s 92 agreements with the Director are named. The Director has the power to disclose the names and addresses of practitioners who are found by a Committee to have engaged in inappropriate practice and who are subject to a final determination.
Read the Director’s policy on the naming of practitioners in PSR's Policy on the Publication of Case Outcomes
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In August 2018, six s 92 agreements entered into between the Director and persons under review came into effect and one final determination came into effect.

A. Director’s Section 92 agreements effective in August 2018

The following agreements entered into by the Director and persons under review (in accordance with s 92 of the Act) came into effect:

  • An agreement with a general practitioner. The Director reviewed this practitioner’s rendering of Medicare Benefits Schedule (MBS) items 23, 36, 44, 900, 2713, 18234, 18236, 30071, 30192, 30195, 30203, 31260, 31270, 31275, 31285, 45203 and 45451 and Pharmaceutical Benefits Scheme (PBS) items 10509D and 2355Y. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items, except for MBS items 30071 and 30195 and PBS items 10509D and 2335Y. The practitioner agreed to repay $380,000, to be disqualified from providing MBS items 44, 900, 18234, 18236, 30192, 30203, 31275, 45203 and 45451 for six months, and will be reprimanded by the Director.
  • An agreement with a general practitioner. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 705, 715, 721, 723, 2717, 5020, 5040, 30192, 66596, 66770 and 69333, and PBS items 10330Q, 2335X, 2622B, 3162K, 8440F, 8562P, 8601Q, 8611F and 8934F. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items, except for MBS item 66770 and PBS items 10330Q and 8601Q, in relation to which the Director had no concerns. The practitioner agreed to repay $248,306.20, to be disqualified from providing MBS item 705 for 12 months, and will be reprimanded by the Director.
  • An agreement with a general practitioner. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 732, 2713, 2715 and 5020. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $150,000 and will be reprimanded by the Director.
  • An agreement with a general practitioner. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 44, 721, 723, 732, 739, 743, 900, 2552, 2558, 2713, 2717, 30071, 30186, 30192, 30196 and 73805, and PBS items 1215Y and 2089Y. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $650,000, to be disqualified from providing MBS items 44, 739, 743, 2552, 2558 and 2713 for 12 months and will be reprimanded by the Director.
  • An agreement with a general practitioner. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723 and 732. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $250,000 and will be reprimanded by the Director.
  • An agreement with a general practitioner. The Director reviewed this practitioner’s rendering of MBS items 197, 721, 723, 732, 2712, 2713 and 2715, and PBS items 1169M, 1760P, 2622B and 3119E. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $420,000 and will be reprimanded by the Director.

B. PSR Committees' final determinations effective in August 2018

PUR 1000 (Dr Farrukh Zia)

One final determination came into effect in August 2018 in respect of Dr Farrukh Zia of Queensland.

Dr Zia was directed to be reprimanded and counselled by the Director, to be disqualified from rendering MBS items 45587, 45617 and 45620 for 12 months, and to repay $440,801.20 to the Commonwealth. These directions followed from a final report of a PSR Committee which concluded Dr Zia engaged in inappropriate practice for services that he rendered as MBS items 53, 54, 597, 599, 5020, 45587, 45617, and 45620 during the review period.

Dr Zia provided services at consulting rooms during in hours periods and provided services for a deputising service during after hours periods. For consultation services (MBS items 53, 54 and 5020), the Committee found that Dr Zia did not always keep adequate entries of the consultations that he billed. Important clinical information such as patient histories, diagnoses, examination findings, plans for management and treatment was not recorded or particularised adequately.

The Committee also found that Dr Zia did not always record sufficient clinical content to justify billing the item that he claimed. For example, consultations that appeared straightforward and obvious and that would not have taken at least 25 minutes to provide, the minimum time for MBS item 54 consultations, were billed as that item. Adequate clinical input was also not always provided in connection with consultation services (although that was not common). Some examples of the instances where clinical input was of concern included where:

  • clinically relevant tasks were not performed or considered
  • a medication was prescribed without considering its interaction with other medications, when doing so was a necessary consideration before prescribing the medication
  • patients presented with certain complaints – such as flu-like complaints – with inadequate evidence of treatment, examination, or the development of a plan for management and
  • medications were re-prescribed without taking an up-to-date history of the patient’s management and without considering whether continued prescribing of that medication was appropriate.

The Committee also found that Dr Zia regularly billed Medicare for what appeared to be routine aftercare following a procedure, despite having previously billed a procedural service for that procedure.

The Committee found that it was inappropriate to bill a consultation item where the only clinical content involved in the consultation related to routine aftercare following a procedural service that been previously claimed under Medicare. For example, the Committee found that in one case Dr Zia billed a consultation item for an attendance a week after he had provided a lesion excision service. The only clinical content involved in the consultation related to the removal of sutures and the discussion of a histopathology report which, in the circumstances of that case, was found by the Committee to constitute routine aftercare. There were numerous other reviewed services where similar findings were made.

In relation to the MBS item 721, 723 and 732 services, the Committee found that Dr Zia billed Chronic Disease Management items despite not complying with all Medicare requirements. It is not possible to bill an ordinary attendance item in addition to a Chronic Disease Management item for the same patient on the same day. This is prohibited by Medicare law and policy.

In numerous cases, Dr Zia billed Chronic Disease Management items the day after, or in the days after, he had billed an ordinary consultation. He did so despite not providing a separate consultation service. Alternatively, if Dr Zia did record that he had seen the patient, there was no separate clinical content involved in the entry that he created to support the billing of a separate consultation service. The entry’s clinical content related only to the Chronic Disease Management service.

The Committee expressed concern (although did not find definitively) that these noncompliant billing practices were adopted to circumvent the restriction on billing ordinary consultation items on the same day as a chronic disease management item. It found this would be unacceptable to the general body of medical practitioners.

In relation to MBS items 597 and 599, the Committee’s findings mostly turned on whether the patient required treatment or assessment urgently in line with the relevant MBS item requirements and whether Dr Zia kept an adequate record of the services. Cases which were not urgent included:

  • a patient who had lumbar back pain
  • a patient who had a sore throat and fever
  • numerous patients who had a viral upper respiratory tract infection and
  • simple ear complaints that were already being actively managed.

The assessment of urgency was made on a case-by-case basis and on consideration of all factual material, including the patient’s clinical record and Dr Zia’s oral evidence. Dr Zia’s recordkeeping for urgent after hours services was also found to be inadequate. For example, information about issues such as patient history, medications, presenting complaints and observations was not always adequately documented.

In relation to MBS items 45587, 45617 and 45620, the Committee found that services were sometimes rendered by Dr Zia for cosmetic reasons or absent a medical reason, as opposed to being medically necessary in accordance with MBS item requirements. The Committee also found that Dr Zia's notes were deficient in crucial aspects, including by failing to disclose the clinical indication for performing the procedures or to support the MBS items that were billed.

On all occasions on which a 45587, 45617 or 45620 service under review was billed, Dr Zia also billed a professional attendance (and sometimes more than one). There was no information discernible from Dr Zia's medical records to support that an independent consultation was rendered, separate to the procedural service(s) rendered. That is, the clinical documentation only referred to the procedural service. Billing professional attendance services without providing or recording any supporting clinical content was found to constitute inappropriate practice.

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 August 2018.

E. Referrals to AHPRA

No matters were referred to AHPRA in August 2018.