PSR Director's Update for October 2017
A. Director’s Section 92 agreements effective in October 2017:
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 36, 705, 707, 721, 723, 732, 2715 and 66716 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items. The practitioner agreed to repay $200,000, will be disqualified from providing MBS items 705 and 707 for 18 months and will be reprimanded by the Director.
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 721, 723, 732 and 5020 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items, except for MBS item 23 in relation to which the Director had no concerns. 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 36, 721 and 723 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items. The practitioner agreed to repay $130,000 and will be reprimanded by the Director.
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 36, 44, 705, 721, 723, 732 and 2713 was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items. The practitioner agreed to repay $200,000, will be disqualified from providing MBS items 44, 705, 721, 723, 732 and 2713 for six months, and will be reprimanded by the Director.
B. PSR Committees’ final determinations effective in October 2017
PUR 957 (Dr William Redmayne)
On 14 September 2017, the Determining Authority made directions in respect of a general practitioner, Dr William Redmayne, who practised at 10A Fleming Street in Nulkaba, NSW 2325 during the 12-month review period. Dr Redmayne was directed to repay $579,542 to the Commonwealth and will receive counselling and a reprimand from the Director of Professional Services Review. These directions followed from a final report of a PSR Committee, which concluded that Dr Redmayne engaged in inappropriate practice for all services he rendered as MBS items 36, 721, 723, 732, 2552, 2712, 2713 and 2715 during the review period. The repayment amount represents the whole of the benefits that were paid for these items during the review period.
The Committee found that, for a considerable number of the randomly sampled services it reviewed (which were all professional attendance services that require a practitioner to personally attend patients), patients were not actually present for services that Dr Redmayne billed.
The Committee also made serious adverse findings in relation to Dr Redmayne’s recordkeeping, clinical input and compliance with MBS requirements.
Level C consultations (MBS item 36)
In relation to MBS item 36, in most cases, the clinical notes did not disclose sufficient clinical content to justify a consultation lasting at least 20 minutes, as required for claiming this item. Compared to other general practitioners, Dr Redmayne was in the 99th percentile for MBS item 36, but he was in only the 39th percentile for MBS item 23. That suggests he may have billed MBS item 36 in circumstances in which other doctors may not have found a longer consultation clinically indicated, or for consultations that did not actually last at least 20 minutes.
The Committee found that on many occasions the clinical record disclosed no more than a straightforward complaint and the record associated with the service was open for much less than 20 minutes. Further, there were deficiencies in Dr Redmayne’s clinical records. Progress notes for MBS item 36 services often contained no relevant patient history, clinical examination findings, investigations, management plans or other clinical content.
There were also deficiencies in Dr Redmayne’s clinical input. For example:
- In one case, there was insufficient evidence that Dr Redmayne assessed a patient presenting with a range of gynaecological symptoms, who had a history of miscarriages and ectopic pregnancies. There was no evidence that he assessed the patient to exclude ectopic pregnancy.
- Another patient presented with genital urinary symptoms, but Dr Redmayne did not examine the patient’s genitals, where doing so was clinically relevant.
- In another case, Dr Redmayne found a suspected cancerous lesion, but failed to undertake or record the findings of a full skin examination.
It was also noted that Dr Redmayne billed MBS item 36 in association with a procedural item, but there was no clinical content recorded that would support the billing of the attendance item.
Chronic disease management services: GP Management Plans (GPMPs) (MBS item 721), Team Care Arrangements (TCAs) (MBS item 723) and review of a GPMP or TCA (MBS item 732)
In the review period, Dr Redmayne rendered MBS items 721 and 723 approximately 300 times (at least 286 times in association). He rendered MBS item 732 nearly 2,105 times (more than twice the 99th percentile for the item), in almost all cases rendering the item twice on the same occasion for a review of both a GPMP and TCA. In relation to MBS item 721, 723 and 732, the Committee found that, except for a few services examined, Dr Redmayne billed these items for work that had not been performed and for patients who had never attended him. Accordingly, none of the MBS requirements were met in connection with rendering this item.
Throughout the records, MBS items 721, 723 and 732 were billed like clockwork on the dates of recall or the following day. The items were billed as soon as the three month regulatory limitation period on billing this item had expired. There was no evidence that patients were present in connection with those services. Routinely, a progress note connected with an apparent CDM service contained no more than a notation that a plan or review had been created and included a recall date for a new plan or review. There were instances of Dr Redmayne commencing CDM services in respect of other patients mere minutes apart, consistent with patients not being in attendance.
In every MBS item 721 service reviewed, the GPMP created on the date of service contained no more than basic patient information (including identifying information, medications and allergies) drawn from the medical records software, a list of diagnoses, and a series of generic ‘goals’ typically including ‘improve general health’, ‘improve knowledge of condition’ and ‘prevent complications’. In no way were the plans comprehensive tools for the ongoing management of patient’s health.
In many of the services reviewed, the progress note merely recorded that a CDM document had been created, but there was no evidence the documentation had been printed or given to patients and/or collaborating providers. GPMPs were often identical to previous plans, with no alterations. The pattern was the same for the MBS item 723 and 732 services. There was negligible clinical content in the documents and the information that was recorded was typically identical to what had appeared in earlier documents in patients’ files.
Therefore, typically, a patient with a GPMP and TCA had both plans reviewed 3 times in the review period. Accordingly, it appears that Dr Redmayne rendered MBS item 732 as soon as he was able to, whether or not a review was clinically indicated and whether any work was done in connection with those reviews. There was no evidence of patients being contacted to come in on any of the dates of recall for a new plan or a review of a plan. Further, for all services examined there was no evidence that GPMPs or TCAs were even printed, let alone given to patients or collaborating providers.
Even leaving aside the above, the documentation relating to MBS items 721, 723 and 732 was of an unacceptable standard. The Committee found that the documents were not capable of improving the management of patients. For example, they contained very generic goals (such as ‘improve mobility’ and ‘improve general health’) without any direction regarding what patients should actually do to achieve those generic goals. The plans were not comprehensive nor tailored to patients’ particular needs.
Additionally, for TCAs, the Committee found that in no case was there reliable evidence that collaborating providers had been communicated with. This was largely borne out by the statistics, which demonstrated that Dr Redmayne rendered MBS item 723 on 289 occasions in the review period but only 115 patients attended allied health practitioners under EPC referrals. Although it is inevitable that some patients will not take up referrals, this corroborated other evidence indicating that a significant number of people did not actually receive referrals.
Asthma – cycle of care plan (MBS item 2552)
The Committee found that Dr Redmayne’s non-compliance with MBS item 2552 was significant. For a number of the services, Dr Redmayne did not record the provision of any clinical input; some services had no notes whatsoever. In other cases, there was no evidence the consultations were pre-planned, dedicated asthma-related consultations. Patients rarely had had another asthma-related consultation in the past twelve months, let alone the two asthma-related consultations that are required by the regulations. The severity of patients’ asthma was not recorded and there was no documentary evidence that the severity of asthma had even been assessed. There was no documentary evidence that patients’ use of and access to asthma related medication and devices was reviewed or that asthma self-management education was provided to patients. In general, this was consistent with minimal or no work being done in connection with rendering this item.
GP mental health treatment plan (MBS item 2715) and review of a GP mental health treatment plan (MBS item 2712)
The Committee made similar findings in respect of Dr Redmayne’s rendering of MBS items 2712 and 2715. For most services, the Committee found that there was no evidence that patients had actually been present on the days on which he billed these items.
These items were billed like clockwork in response to reminders that were set to render the items 3 months and 1 day after the item was previously billed. The Committee found this timeline was set to bill the items as soon as they could be billed again, regardless of whether any work was done in connection with the items or whether patients were present.
For both MBS item 2712 and 2715, there was little evidence that any clinical work was performed in relation to these items. The plans that were prepared entirely inadequate. The plans contained generic goals, like ‘minimise symptoms and distress’ and ‘prevent complications’, rather than tasks, actions and goals that might be of some use to the patient and that could be reviewed at a later stage. The plans contained no assessment of patients’ needs. There was no evidence that outcome assessment tools had been administered, a task that must be done when rendering these items unless clinically irrelevant.
For MBS item 2712, in not a single case did Dr Redmayne make any amendments to a previous care plan. The Committee found it was inconceivable that none of the reviewed plans required no amendments. Further, because the previous mental health treatment plan was of such a poor quality, it was not possible to meaningfully review patients’ care plans.
On the few occasions where there was clinical content in the progress note corroborating that patients had actually attended Dr Redmayne on days on which he billed MBS items 2712 or 2715, there was typically some minimal psychosocial history recorded in the plan. The plans were nonetheless of an unacceptably poor quality.
Mental health consultation (MBS item 2713)
In most cases, the Committee found the clinical notes did not disclose sufficient clinical content to justify a consultation lasting at least 20 minutes, as required for claiming MBS item 2713. In some cases, the notes did not disclose a presenting mental health complaint but rather suggested the patient had attended with some physical ailment.
Universally, the progress notes for MBS item 2713 contained no mental health assessment and were otherwise inadequate. Usually, the progress notes missed important information including a relevant history, any advice given, and the outcomes of the consultation.
The Committee also found that the consultations either did not last 20 minutes or the clinical content recorded in Dr Redmayne’s progress notes was not sufficient to justify a consultation lasting at least 20 minutes.
C. Federal Court
The decision in the judicial review application mentioned last month remains reserved.
D. Referrals to the major non-compliance (fraud) division
One matter was referred to the major non-compliance (fraud) division in October 2017.
E. Referrals to AHPRA
Two matters were referred to AHPRA in October 2017. One matter was referred for non-compliance with professional standards and the other for non-compliance with professional standards and endangering the life or health of patients.