PSR Director's Update for June 2021

19 July 2021

 

 

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.
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Read the Director’s policy on the naming of practitioners in PSR's Policy on the Publication of Case Outcomes

Six section 92 agreements and three final determinations came into effect in June.

A. Director’s Section 92 agreements effective in June 2021

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

During the review period, the practitioner rendered Medicare Benefit Schedule (MBS) item 585 and 2717 services in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 585, 5049, 721, 723, 732, 2717 and 10997, and Pharmaceutical Benefits Schedule (PBS) items 1215Y and 8254K. The Director had persisting concerns that:

  • the MBS requirements were not always met, including the minimum time requirements
  • the practitioner’s records were inadequate
  • the practitioner did not always provide adequate clinical input and
  • the practitioner prescribed PBS items 1215Y and 8254K outside of the PBS restrictions and without appropriate clinical indication.

The practitioner acknowledged having engaged in inappropriate practice in connection with rendering these items of concern. The practitioner agreed to repay $365,000, to be disqualified from providing MBS items 721, 723, 2717 and 10997 for 12 months, and will be reprimanded by the Director.

An agreement with a radiologist

During the review period, the practitioner was the highest provider of MBS item 63001 services rendered in association with MBS item 63055 services across all diagnostic radiology specialists in Australia. The Director reviewed this practitioner’s rendering of MBS items 104, 105, 55848, 63001, 63007, 63040, 63055, 63167, 63173 and 63176. The Director had persisting concerns that:

  • For MBS item 104 and 105 (specialist attendance following a referral):
    • there was no evidence of personal attendance by the practitioner on the patient for the purposes of a consultation
    • there was no referral requesting a specialist consultation and the service was not otherwise clinically indicated
  • multiple MRI brain (63001, 63007, 63040 and 63055) and spine MRI items (MBS items 63167, 63173 and 63176) were co-billed where a single service was performed and reported
  • MRI brain and spine items were consistently co-billed with other similar items where not all items were requested or otherwise clinically indicated
  • informed consent for interventional procedures performed in association with imaging was either not obtained or not adequately documented and
  • records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $230,000, to be disqualified from providing MBS item 104, 105 and 63055 services for 12 months and will be reprimanded by the Director.

An agreement with a radiologist

During the review period, the practitioner was the highest provider of MBS item 63001 services rendered in association with MBS item 63049 services of all active diagnostic radiology specialists in Australia. The Director reviewed this practitioner’s rendering of MBS items 104, 105, 55848, 63001, 63007, 63040, 63049, 63167, 63173, 63176 and 63129.

The Director had persisting concerns that:

  • MBS item 104 and 105 services were billed in circumstances where the services were performed by other practitioners using the practitioner’s provider number
  • MBS item 104 and 105 were billed without a referral for a specialist consultation or a record of a separate consultation having occurred
  • MRI brain and spine items were consistently co-billed with other similar items where not all items were requested or otherwise clinically indicated and
  • when MRI brain and spine items were co-billed, there was only one scan performed and report provided which did not separately address each of the clinical conditions relevant to each MBS item claimed.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $538,413.70, to be disqualified from providing MBS item 104 and 105 services for 12 months and will be reprimanded by the Director.

An agreement with a radiologist

During the review period, the practitioner rendered MBS item 63001 in association with MBS item 63007 in excess of 99 percent of their peers. The Director reviewed the practitioner’s rendering of MBS items 104, 105, 55850, 57360, 63001, 63007, 63040, 63064, 63173 and 63176. The Director had persisting concerns that:

  • MBS item 104 and 105 services:
    • were billed without referral for a specialist consultation or any record of a separate consultation having occurred
    • had no record of communication reporting back to the referring practitioner
    • were co‑billed with MBS item 55850 and 57360 services without any record of a separate consultation
  • The item requirements for MBS 55850 were not met 
  • MRI brain and spine items were consistently co-billed with other MRI brain or MRI spine items where not all items were requested or otherwise clinically indicated and
  • informed consent was not always appropriately obtained and recorded for all interventional procedures during the review period.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $120,000 and be reprimanded by the Director.

An agreement with a radiologist

During the review period, the practitioner was the highest provider of MBS item 63176 services rendered in association with MBS item 63179 services of all diagnostic radiologists in Australia. The Director reviewed the practitioner’s rendering of MBS items 104, 105, 55848, 63001, 63007, 63046, 63167, 63173, 63176 and 63179. The Director had persisting concerns that:

  • MBS item 104 and 105 services:
    • were billed to the practitioner’s provider number where there was no evidence of a personal attendance by the practitioner on the patient for the purposes of a consultation
    • had no record of communication reporting back to the referring practitioner 
    • had no referral requesting a specialist consultation, and the service was not otherwise clinically indicated.
  • reports of MRI services performed were inadequate 
  • not all billed MRI brain and spine items were requested or otherwise clinically indicated
  • when MRI brain and spine items were co-billed, there was only one scan performed and report provided which did not separately address each of the clinical conditions relevant to each item claimed
  • the MBS requirements were not always met
  • informed consent to interventional procedures performed in association with imaging was either not obtained or not adequately documented and
  • the records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $750,000, to be disqualified from providing MBS item 104 and 105 services for 12 months and be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner rendered MBS items 721 and 11610 in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 721, 723, 732, 11610 and 11700. The Director had persisting concerns that:

  • the MBS requirements, including minimum time requirements, were not always met
  • the diagnostic procedures provided were not always clinically indicated. For example, MBS 11610 appeared to be done for screening purposes, and before performing a peripheral pulse or leg claudication examination and
  • the records were inadequate.

The practitioner acknowledged having engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $220,000, to be disqualified from providing MBS items 36, 721, 723, 723 and 11610 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

PSR Committee No. 1178

On 25 June 2021 a final determination came into effect regarding a medical practitioner who practised in Victoria during the review period. The practitioner was directed to:

  • be reprimanded and counselled
  • repay $221,152.30 to the Commonwealth and
  • be disqualified from rendering MBS item 721, 723, 732 and 2713 services for a period of 12 months.

The directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in connection with services provided as MBS items 721, 723, 732, 2713, 5020, 5040 and 5060.

The Committee was concerned about the practitioner’s record keeping, compliance with MBS requirements and that not all services were clinically indicated. The Committee also considered that the practitioner’s clinical input was inadequate in a number of instances, particularly in relation to the practitioner failing to perform necessary examinations, referrals or tests, failing to establish a plan to manage the patient’s presenting complaint and in failing to follow up abnormal test results.

In relation to the practitioner’s rendering of MBS item 721, 723 and 732, the Committee made widespread findings of inappropriate practice on the basis that the patient did not attend on the date of service. The Committee also considered that the documentation was inadequate and the MBS requirements were not met, including that the patient did not have an eligible chronic condition. The Committee also considered that some MBS item 723 and 732 services were not clinically indicated.

With respect to the MBS item 2713 services, the Committee made findings of inappropriate practice on the basis that the MBS requirements were not met including because there was insufficient clinical content to require a consultation of at least 20 minutes’ duration. The Committee also considered that the records were inadequate, the services were not clinically indicated and, in one instance, the patient was not in attendance for the service.

The Committee made findings of inappropriate practice in relation to the provision of services for attendance items 5020, 5040 and 5060 on the basis that the MBS requirements were not met, the records were inadequate and the patient was not always in attendance on the date of service.

The Determining Authority’s repayment direction of $221,152.30 along with the 12 month disqualification from MBS items 721, 723, 732 and 2713 reflects the serious extent of inappropriate practice found by the Committee. The practitioner will also receive a reprimand and counselling from the Director.

PSR Committee No. 1206

On 16 June 2021 a final determination came into effect regarding a medical practitioner who practised in Sydney, New South Wales. The practitioner was directed to:

  • be reprimanded
  • repay $258,836.31 to the Commonwealth and
  • be disqualified from rendering MBS item 585, 588, 591, 594 and 600 services for a period of 12 months.

These 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 598 and 600, being for urgent after-hours attendances during the review period, and the provision of PBS item 8254K (amoxicillin with clavulanic acid).

The Committee’s findings largely concerned the practitioner’s record keeping, and their failure to comply with MBS requirements for MBS items 598 and 600, including the requirements for an attendance being regarded as ‘urgent’.  The Committee observed that the practitioner’s records were brief, often not containing a patient history or adequate examination and in some instances were difficult to follow. The Committee considered it would be difficult for another practitioner to assume care for the practitioner’s patients based on the information in the records. With regards to PBS item 8254K, the Committee found that the regulatory requirements of MBS item 8254K were not met where the practitioner prescribed the antibiotic without a record or indication of resistance to amoxicillin.

The disqualification reflects that MBS item 598 is no longer on the MBS Schedule and has in effect been replaced by MBS items 585, 588, 591 and 594.

PSR Committee No. 1208

On 16 June 2021, a final determination came into effect regarding a medical practitioner who practised in Queensland, during the review period.  The practitioner was directed to:

  • be reprimanded
  • repay $313.216.88 to the Commonwealth and
  • be disqualified from rendering Medicare Benefit Schedule (MBS) items 585, 588, 591, 594 and 599 services for a period of six months.

The directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in connection with services provided as MBS items 597 and 599. 

The Committee made findings of inappropriate practice across both MBS items 597 and 599 on the basis that the MBS requirements were not met as the patient’s condition did not require urgent treatment that could not be delayed to the start of the next in-hours period, or alternatively, if there was some element of the service that rendered it urgent, this was not adequately recorded in the progress note and the medical record was inadequate.

The Committee also made findings of inappropriate practice on the basis that the medical records were inadequate as the recorded patient history and examination often lacked important details pertinent to the presenting complaint. The records also failed to document appropriate follow-up arrangements. In a small number of MBS item 599 services findings of inappropriate practice were made on the basis that the practitioner provided inadequate clinical input into the service.

The Determining Authority’s repayment direction of $313,216.88 (being 75% of the Medicare benefits that were paid for the MBS item 597 and 599 services where a finding of inappropriate practice was made) reflects that the conduct of the practitioner’s employer materially affected the practitioners conduct during the review period and the conduct of the employer was materially deficient in key respects. The disqualification period of six months reflects an appropriate outcome given the extent and nature of the inappropriate practice and the changes the practitioner has made to their practice. The disqualification reflects that MBS item 597 is no longer on the MBS Schedule and has in effect been replaced by MBS items 585, 588, 591 and 594.

C. Federal Court

One federal court decision was handed down in June 2021.

Yoong v The Chief Executive Medicare & Director of PSR [2021] FCA 701

Dr Yoong challenged the decision of the delegate of the Chief Executive Medicare (CEM) to request the Director of PSR to review his provision of services. He also challenged the decision of the Director to conduct the review. The question was whether Dr Yoong was owed procedural fairness by the delegate of the CEM, and if so, whether this had been adequately provided.

The Court dismissed Dr Yoong’s application, finding that the requisite process had been properly complied with by both the CEM and the Director of PSR.

The Department of Health and PSR were awarded costs.

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

No matters were referred to the major non-compliance (fraud) division in May 2021.

E. Referrals to AHPRA (106XA/B)

Two matters were referred to AHPRA in June 2021.