PSR Director's Update for February 2018
In February 2018, 4 negotiated agreements and 2 final determinations came into effect.
A. Director’s Section 92 agreements effective in February 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 MBS items 23, 701, 723, 707, 2715, 5020, 31205, 31230, 31235, 63173, 63176, 63179, 63322, 63325, 63328, 63331, 63337 and PBS items 3119E, 3095X, 9349C, 9044B, 2574L, 9023X, 08888T and 8611F was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing MBS items 721, 723, 31205, 31230, 31235, 63173, 63176, 63179, 63322, 63337, 63325, 63328 and 63331 and PBS items 3119E, 3095X, 9044B, 2574L, 9023X and 8611F. The practitioner agreed to repay $90,000 and will be reprimanded by the Director.
- An agreement with a radiologist. This practitioner’s rendering of MBS items 53, 104, 105, 18216, 18274, 39013, 57712, 57715 and 58121 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items except for MBS items 57712, 57715 and 58121, in relation to which the Director had no concerns. The practitioner agreed to repay $180,000 and will be reprimanded by the Director.
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 721, 723, 2713, 66596, 66719, 66839 and 71166 and PBS items 2622B, 8387K, 8118G, 3162K, 8386J, 8501K and 8502L was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items except for PBS item 8501K. The practitioner agreed to repay $300,000 and will be reprimanded by the Director.
- An agreement with a medical practitioner. This practitioner’s rendering of MBS items 53, 54, 721, 732, 2712, 2717 and 5207 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to be disqualified from Medicare for a period of 3 years and will be reprimanded by the Director.
B. PSR Committees’ final determinations effective in February 2018
The Determining Authority made final determinations in respect of two general practitioners, each of which became effective in February 2018.
PSR Committee No. 928
For this case, a general practitioner was directed to repay $276,154.82 to the Commonwealth and will receive counselling and a reprimand from the Director. These directions followed from a final report of a PSR Committee that concluded the practitioner engaged in inappropriate practice for services he billed as MBS items 707, 721, 723, 731 and 732 during the review period.
For each item, the Committee found that the practitioner failed to meet MBS requirements, did not provide adequate clinical input and/or did not keep adequate records.
MBS item 707
For MBS item 707, in a number of cases the Committee found that the practitioner did not attend any patients specifically for the purposes of the health assessments. Instead, the practitioner relied extensively on a practice nurse to do the work associated with health assessments. That alone would have caused the Committee to find inappropriate practice, but additional or alternative findings were made. These included that the health assessments often failed to comprehensively collect information necessary for the health assessment. In many cases, the practitioner did not record the medications patients were taking and failed to record any immediate actions or recommendations for patients.
Some health assessments were created before the patient was eligible to receive a further health assessment (that is, within 12 months of their previous health assessment). The practitioner also billed MBS item 707 before he had completely rendered a health assessment service.
For many services reviewed, the Committee found the practitioner relied extensively on template generated health assessment documents and failed to input any patient specific information into those templates. The health assessments were automatically generated and not personalised for the particular circumstances of each patient. Many health assessments had the same content recorded (such as ‘no murmurs’ and ‘chest clear’) even when that could not have been accurate information for individual patients. The practitioner acknowledged that he did not revise his health assessments to ensure their accuracy.
MBS items 721, 723, 731 and 732
For MBS item 721 (GP Management Plans (GPMPs)), the Committee found that the practitioner did not record that he personally attended patients for the purposes of preparing a GPMP. The practitioner had delegated the task of preparing the GPMPs to his practice nurse and his personal involvement in the services was not clear.
The Committee found that the practitioner or his practice nurse staff billed and/or prepared GPMPs before the patient was eligible to receive a repeat GPMP (that is, before the expiry of the 12-month limitation period) and where there were no exceptional circumstances to justify doing so. This was considered contrary to the requirements of the relevant regulations and the expectations of the general body of general practitioners.
The Committee also found that the practitioner did not provide adequate clinical input into GPMP services. There were also systematic inaccuracies in GPMPs. For example, measurements were not taken, medication list errors were left uncorrected, and other related clinical tasks were not performed.
For MBS item 723 (Team Care Arrangements (TCAs)), the Committee found that the practitioner billed TCAs before patients were eligible, contrary to the requirements of the MBS descriptor. It also found he billed Medicare for an MBS item 723 service before the TCA had been fully rendered. The practitioner did not obtain consent from at least two of the collaborating providers that were nominated to participate in the TCA or otherwise consult with practitioners when coordinating TCAs.
The documents included generic phrases which indicated that verbal consent had been obtained but no other evidence to suggest service-specific collaboration occurred or that TCAs were developed with the benefit of consultation with collaborating providers.
For MBS item 731 (multidisciplinary care plans), the Committee found the practitioner automatically billed these services on a three-monthly basis, which was the only reason precipitating the billing of the item, including in one case where an MBS item 731 service was billed for a deceased patient. There was also limited or no evidence of collaboration with residential aged care facilities or evidence that the practitioner reviewed the multidisciplinary care plans.
For MBS item 732 (review of a GPMP or TCA), the Committee found the practitioner failed to meet the MBS item descriptor requirements as he billed this item before the patient was eligible to have their GPMP or TCA reviewed, contrary to the requirements of the item descriptor.
In many cases, the billing of an MBS item 732 service was precipitated by a recall system rather than any clinical necessity that could have justified billing the service. In many cases, the Committee found that no changes were made to GPMPs or TCAs on days on which the practitioner billed an MBS item 732 service. No corrections were made to deficiencies in the original care plans.
The Committee also found that the practitioner did not consult with collaborating providers in undertaking TCA reviews.
PSR Committee No. 994
In this case, a general practitioner was directed to repay $269,756.21 to the Commonwealth, to be disqualified from rendering MBS items 597 and 599 for three months, and will receive counselling and a reprimand from the Director. These directions followed from a final report of a PSR Committee that concluded the practitioner engaged in inappropriate practice for services he rendered as MBS items 36, 597, 599, 5040 and 66716 during the review period.
MBS items 36 and 5040
The Committee found in many cases that the records were inadequate to the extent that they would be considered unacceptable to the general body of general practitioners. The Committee found that the practitioner relied heavily on templates and, on occasion, copying and pasting from other clinical records such that his examination findings looked very similar between different consultations and between patients. The Committee was particularly doubtful that the template-based examination entries accurately reflected the content of consultations. Often the matters indicated in the template were not clinically relevant and examinations that would have been clinically relevant (which may have been done) were not recorded. Specific measurements did not vary between consultations and the practitioner agreed that sometimes those measurements were part of the template.
Often the same examination was purportedly done multiple times in a short space of time without a supporting clinical indication. The Committee reported that the practitioner could not always be sure that he had performed the examinations leading to the template-based findings. The Committee also considered that there was a surprising lack of abnormal examination findings, suggesting that on some occasions, even if there was a minor abnormality, it was not recorded. For example, the vast majority of the notes of the reviewed services contained the notation ‘S1 S2 no murmurs’. The Committee considered it unlikely that all patients had no murmurs. In general, the records made it difficult to know precisely what was and was not done in connection with an examination and whether the results of examinations were accurately recorded in any particular case.
The Committee found that the practitioner’s history recording was typically very limited. He would usually record the presenting complaint and its duration with some precision, but not any history of severity or associated symptoms. Further, even very specific history was sometimes part of a template and not tailored to patients’ actual presenting complaint(s). The clinical content documented in the records in general was not consistent with consultations that would have lasted at least 20 minutes and of an appropriate complexity associated with Level C consultations.
Some examples of this conduct that, in isolation and/or combination with other conduct was found to be inappropriate, included:
- The record of a consultation with a patient who had Hepatitis A was inadequate, including because there was insufficient evidence that the practitioner had examined the patient’s liver and an adequate history was not taken.
- An adult examination template was used (without customisation) for examinations of an 18-month-old baby. Age appropriate examinations were accordingly either not conducted or documented inadequately.
- A pelvic examination was not conducted for a patient who had a previous history of pelvic complications and for whom ectopic pregnancy may have been possible. The practitioner also did not consider the patient’s relevant history, initiate adequate investigations and follow-up.
MBS items 597 and 599
For MBS items 597 and 599 (urgent consultations during either sociable or unsociable after hours periods), the Committee was satisfied that all the randomly selected services occurred in the applicable after-hours period. Its findings generally turned on whether patients required urgent treatment and whether the practitioner kept an adequate record of the service.
MBS items 597 and 599 both require, among other things, that ‘the patient’s medical condition requires urgent treatment.’ The Committee found that in a number of cases patients did not require urgent treatment or even urgent assessment. The Committee found that the practitioner had automatically billed MBS items 597 and 599, irrespective of whether the patient was required urgent treatment or assessment.
The records for MBS item 597 and 599 services typically followed a particular template. The notes were often lacking in detail or were misleading.
The Committee also found that adequate clinical input was not provided in some cases. For example, this was the case when examinations that were clinically necessary were not conducted, where differential diagnoses were not considered or diagnoses made without enough information, and where adequate history was not taken.
The Committee also reviewed the practitioner’s initiation of MBS item 66716 (initiation of thyroid stimulating hormone quantitation). The Committee found that in all but two cases this item was initiated in the absence of an adequate clinical justification. This alone was considered to be unacceptable to the general body of general practitioners.
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 February 2018.
E. Referrals to AHPRA
One matter was referred to AHPRA in February 2018.