PSR Director's Update for January 2020

10 February 2020

 

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
For media enquiries, please contact PSR at 02 6120 9100 or feedback@psr.gov.au.

In January 2020, seven s 92 agreements came into effect and two final determinations became effective.

A. Directors Section 92 agreements effective in January 2020

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 radiologist.

During the review period, the practitioner billed Medicare Benefits Schedule (MBS) item 18222 more than 1,600 times and MBS item 18225 more than 400 times.  The Director reviewed this practitioner’s provision of MBS items 104, 18222, 18225, 55808, 55816, 55828, 55836 and 55850 and had no concerns in relation to MBS items 55808, 55816, 55828, 55836 and 55850. The Director had persisting concerns that the practitioner provided MBS items 104, 18222 and 18225, in circumstances where:

  • MBS item 104 was often co-billed with a procedural item. In those instances, there did not always appear to be evidence of a MBS item 104 consultation that met the MBS requirements separate to the performance of a procedure;
  • there was often no documented evidence of a referral for a separate specialist consultation;
  • the record did not always contain a valid referral for the MBS item 104 service;
  • the record was inadequate; and
  • MBS items 18222 and 18225 were billed where the practitioner appeared to provide a single injection rather than an infusion.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $150,000, to be disqualified from providing MBS items 104, 18222, 18225 for 12 months, and will be reprimanded by the Director.

An agreement with an endocrinologist.

This practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 116, 132 and 133. The Director had persisting concerns that:

  • the MBS requirements for these items were not always met, including the minimum time requirements. In services where MBS items 132 and 133 were billed, there was often no evidence that a comprehensive management plan was created addressing physical psychological and social factors;
  • the records did not always reflect that the practitioner personally attended the patient when billing attendance items;
  • the practitioner did not always keep adequate records of the services they provided. In particular, the practitioner’s letters back to the referring general practitioner did not contain sufficient clinical detail;
  • not all services were clinically indicated; and
  • the practitioner did not always provide adequate clinical input into each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $790,000, to be disqualified from providing MBS items 132 and 133 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

This practitioner billed MBS item 5040 in excess of 99 percent of their peers and MBS item 36 in excess of 98 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 721, 723 and 5040, and prescribing of Pharmaceutical Benefits Scheme (PBS) item 8254K. The Director had persisting concerns that:

  • the practitioner’s records were inadequate;
  • MBS item requirements were not always met. Often the time requirements for MBS items 36, 44 and 5040 did not appear to be complied with. The requirements for MBS items 721 and 723 were not always met because, on occasion, the practitioner appeared to provide these services to patients who did not have a suitable chronic disease. Where MBS item 723 was billed, there was often no evidence of two way communication with two other healthcare providers; and
  • PBS item 8254K was prescribed in instances where the PBS item requirements were not met and where it was not clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $150,000, to be disqualified from providing MBS item 44 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

This practitioner billed in excess of 87 percent of their peers, despite having a patient load on the 22nd percentile during the review period. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 721, 723, 732, 2525, 2558, 2717 and 73805 and had no concerns about MBS item 2525. In respect of the remaining items, the Director had persisting concerns that:

  • the MBS requirements were not always met. The records for MBS items 36, 44, 2558 and 2717 often contained insufficient clinical input to justify the minimum time requirement outlined in the MBS item descriptor;
  • for services billed as MBS item 73805, the practitioner appeared to perform a dipstick urinalysis rather than a urine microscopy or catalase test; and
  • the practitioner’s medical records were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing the items of concern. The practitioner agreed to repay $410,000, to be disqualified from providing MBS items 36, 44, 2558 and 73805 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, this practitioner provided MBS item 721 in excess of 94 percent of their peers, MBS item 723 in excess of 95 percent of their peers and MBS item 732 in excess of 98 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 721, 723, 732, 2713, 2715, 10997 and 11610, and PBS item 8254K, and had no concerns in relation to PBS item 8254K. The Director had persisting concerns that:

  • where chronic disease management services were billed (MBS items 721, 723, 732 and 10997), the documentation was not sufficiently individualised to the patient. MBS item 10997 appeared to billed where the nurse prepared the GP Management Plan (GPMP) or Team Care Arrangement (TCA) rather than performing a service consistent with an established GPMP, TCA or multidisciplinary care plan;
  • where mental health services were billed (MBS items 2713 and 2715), the records were inadequate and did not support that the minimum time requirements were always met; and
  • MBS item 11610 was provided where the test did not appear to always be clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $150,000, to be disqualified from providing MBS items 721, 723, 732, 2713 and 11610 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

During the review period, this practitioner billed MBS item 721 in excess of 98 percent of their peers and MBS items 723 and 732 in excess of 97 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723, 732 and 2713. The Director had persisting concerns that:

  • the MBS requirements were not always met, including the minimum time requirements (where relevant). The requirements for MBS items 721 and 723 were not always met because, on occasion, the practitioner appeared to provide these services to patients who did not have a suitable chronic disease. Where MBS item 723 was billed, there was often no evidence of two way communication with two other healthcare providers. For MBS item 2713, the practitioner did not always appear to use an outcome tool or document a management plan;
  • the practitioner’s records were inadequate, particularly because the records often contained identical text being present across and within patient files; and
  • some services provided were not clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $90,000, to be disqualified from providing MBS items 732 and 2713 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

This practitioner billed more than 21,000 services during the review period. The Director reviewed this practitioner’s provision of MBS items 23, 5020, 66650 and 69481, and PBS items 2335X, 5490Y, 7530H and 8601Q. The Director had persisting concerns that:

  • the practitioner’s records were inadequate;
  • the practitioner did not always provide sufficient clinical input into each service;
  • the MBS requirements were not always met;
  • MBS items 66650 and 69481 were not always clinically indicated; and
  • PBS items 2335X, 5490Y and 7530H were prescribed in circumstances where the PBS requirements were not met.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $165,000, to be disqualified from providing MBS item 66650 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

Two final determinations became effective in January 2020.

PSR Committee No. 1054

On 9 January 2020, a final determination came into effect concerning a general practitioner who practised in Victoria during the year under review. The practitioner was directed to be reprimanded, directed to repay $32,189.50 to the Commonwealth and was directed to be disqualified from Medicare for a period of five years. The directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in connection with services rendered as MBS items 23, 36, 44, 721, 732, 2712, 2713 and 2715.

The Committee’s specific findings for each of the referred services were for the following reasons:

In relation to MBS item 36, the Committee found, variously, that:

  • there was insufficient clinical input recorded to justify a consultation lasting at least 20 minutes as required;
  • the practitioner’s clinical input into the service was inadequate;
  • the patient did not attend on the date of service in some cases; and
  • the practitioner’s clinical record was inadequate, including that it did not disclose a separate condition requiring immediate treatment to that addressed in the concurrent MBS item 2713 service that was co-billed.

In relation to MBS item 44, the Committee found, variously, that:

  • MBS requirements for the service were not always met, including that the clinical input recorded was not sufficient to justify a consultation lasting at least 40 minutes;
  • the practitioner’s clinical input into the service was inadequate and in some cases the clinical input was inappropriate;
  • patients’ mental health problems were addressed in a concurrent MBS item 2713 service and where there was a separate presenting complaint, it did not always require immediate treatment; and
  • the practitioner’s clinical record was inadequate.

In relation to MBS items 721 and 732, the Committee found that:

  • MBS requirements for services were not always met, including that there was no GPMP or a review of such a plan located in the record;
  • evidence did not always support that the patient attended on the date of service;
  • the practitioner’s clinical input into the service was inadequate;
  • the service was not always clinically indicated;
  • the practitioner was not always the patient’s usual general practitioner as required; and
  • clinical record was inadequate.

In relation to MBS item 2712, the Committee found that:

  • MBS requirements were not met, including that the evidence did not always support that the patient attended on the date of service or that a review of a GP Mental Health Treatment Plan had occurred;
  • the service did not always relate to a mental health problem as required; and
  • clinical records were inadequate.

In relation to MBS item 2713, the Committee found that:

  • MBS requirements were not always met, including that the record of the practitioner’s clinical input was inadequate to justify a consultation lasting at least 20 minutes;
  • consultations reflected the normal preparation of a GP Mental Health Treatment Plan for which MBS item 2715 was rendered separately;
  • services were not always in relation to a mental health problem; and
  • clinical records were inadequate.

 In relation to MBS item 2715, the Committee found that:

  • MBS requirements were not always met, including that there was no GP Mental Health Treatment Plan documented in the records;
  • records of the practitioner’s clinical input were insufficient to justify a consultation lasting at least 20 minutes; and
  • clinical records were inadequate.

PSR Committee No. 1128

On 21 January 2020, a final determination came into effect concerning Dr Samuel Wu, a general practitioner who practised in Rosanna, Victoria during the year under review. Dr Wu was directed to be reprimanded and counselled, directed to repay $295,457.56 to the Commonwealth and was directed to be disqualified from providing MBS items 36, 197, 5040, 5043, 5060 and 5063 for a period of 12 months. The directions followed from a final report of a PSR Committee, which concluded that Dr Wu engaged in inappropriate practice in connection with services provided as MBS items 36, 44, 197, 5040, 5043, 5060 and 5063 and PBS items 3133X and 3162K. 

The Committee’s specific findings for each of the referred items were for the following reasons:

In relation to MBS items 36, 5040 and 5043, the Committee found that:

  • MBS requirements were not always met in that the clinical record did not contain sufficient information to justify a consultation of at least 20 minutes in duration;
  • Dr Wu’s clinical input into services was inadequate;
  • services were not always clinically indicated;
  • acupuncture treatment provided during services was not always clinically indicated; and
  • Dr Wu’s clinical records were inadequate.

In relation to MBS items 44, 5060 and 5063, the Committee found that:

  • MBS requirements were not always met in that the clinical record did not contain sufficient information to justify a consultation of at least 40 minutes in duration;
  • services were not always clinically indicated;
  • Dr Wu’s clinical input into some services was inadequate and at times inappropriate; and
  • clinical records were inadequate, including that they did not contain a patient summary, list of diagnoses and medications, or correspondence with other medical practitioners.

In relation to MBS item 197, the Committee found that:

  • MBS requirements were not always met in that the clinical record did not contain sufficient information to justify a consultation of at least 20 minutes in duration;
  • Dr Wu’s clinical input into services was inadequate;
  • services were not always clinically indicated; and
  • Dr Wu’s clinical records were inadequate.

In relation to PBS items 3133X (oxazepam 30mg tablet) and 3162K (diazepam 5mg tablet), the Committee found that the:

  • Dr Wu’s clinical input into services was inadequate; and
  • Dr Wu’s clinical records were inadequate.

C. Federal Court

No decisions from the Federal Court were handed down in January 2020.

D. Referrals to the major non-compliance (fraud) division (89A & 106N)

No matters were referred to the major non-compliance (fraud) division in January 2020.

E. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in January 2020.