PSR Director's Update for September 2017
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 email@example.com.
In September 2017, 5 negotiated agreements and 2 final determinations came into effect.
A. Director’s Section 92 agreements effective in September 2017
The following agreements entered into by the Director and persons under review (in accordance with s92 of the Act) were ratified:
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 31210, 31215, 31230, 31240, 31260, 31270, 31285, 31290, 31330, 45200, 55038, 55065, 55076 and 59300, and prescribing of PBS item 8440F, were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items except for PBS item 8440F, in relation to which the Director had no concerns. The practitioner agreed to repay $43,558, and will be reprimanded by the Director.
- An agreement with an ophthalmologist. This practitioner’s rendering of MBS items 42702, 42740 and 42788 were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering all of these items. The practitioner agreed to repay $750,000, and will be reprimanded by the Director.
- An agreement with a nuclear medicine physician. This practitioner’s rendering of MBS items 12306, 12312, 12315 and 12323 were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering all of these items. The practitioner agreed to repay $1,100,000, to be disqualified from rendering MBS items 12306, 12312, 12315 and 12323 for 18 months from certain practice premises, and will be reprimanded by the Director.
- An agreement with a consultant sleep and respiratory physician. This practitioner’s rendering of MBS items 11503 and 12203 were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering all of these items. The practitioner agreed to repay $2,000,000, to be disqualified from rendering MBS items 11503 and 12203 for 3 years, and will be reprimanded by the Director.
- An agreement with a general practitioner. This practitioner’s rendering of MBS items 53, 721, 723, 732, 735, 2715, 5020, 66596, 66839 and 69333 were reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with rendering all of these items. The practitioner agreed to repay $730,000 and will be reprimanded by the Director.
B. PSR Committees’ final determinations effective in September 2017
PUR 940 (Dr Constantinos Perkoulidis)
On 3 August 2017, the Determining Authority made directions in respect of a medical practitioner practising in general medicine, Dr Constantinos Perkoulidis, who practised at Brunswick Hill Medical Clinic, 544 Sydney Road, Brunswick, Victoria 3056 during the review period. Dr Perkoulidis was:
- Directed to repay $392,154.60 to the Commonwealth
- Fully disqualified from providing all Medicare services for six months
- Disqualified from rendering MBS items 707, 721, 723, 732, 900, 2713, 13939, 30064, 30067, 30219, 32174, 41500, 41677 and 42644 for two years.
These directions followed from a final report of a PSR Committee, which concluded that Dr Perkoulidis engaged in inappropriate practice for all services he rendered as MBS items 707, 721, 723, 732, 900, 2713, 13939, 30064, 30219, 32174, 41500, 41677 and 42644 during the 12-month review period.
The reasons for the Committee’s findings were wide-ranging and concerning. In general, the Committee found that Dr Perkoulidis’s records were startlingly deficient in important clinical information to establish the nature of services performed or whether the MBS requirements had been satisfied and, indeed, whether services were actually provided. For many services there was simply no documentation that had been created in connection with the billing of a Medicare service.
In relation to the MBS item 707 services (prolonged, one hour health assessments), Dr Perkoulidis only claimed this health assessment item during the 12-month review period; he did not bill shorter health assessments. The Committee found that documentary evidence to support the claiming of this item was either non-existent or inadequate, with no supporting documentation created in 24 out of 30 randomly sampled, reviewed services. Where documentation did exist, it was of a very poor quality or not capable of supporting a claim for MBS item 707. The Committee doubted that many of the services had been performed at all and considered it was more likely that Dr Perkoulidis periodically claimed for the item number without actually performing any of the work required by this item.
In relation to the MBS item 721 services, the Committee found that in 26 out of 28 cases reviewed there was no GP management plan (GPMP) created on the dates of service, and on the other two occasions the document only contained information that was automatically populated from medical records software that was inaccurate and not relevant to the patient. Accordingly, the Committee was not satisfied that any clinical input had been provided in preparing the GPMPs, or that the MBS requirements for the item had been met.
In relation to the MBS item 723 services, the Committee found that the services did not meet the MBS requirements for this item and an adequate record of the services had not been made. The Committee found that Dr Perkoulidis had not understood, or had otherwise had little regard to, the fundamental requirements of rendering MBS item 723; that is, to collaborate with at least two other contributing providers (of which at least one must be an allied health practitioner) and to prepare a document setting out the different responsibilities of the various providers and the patient. In most (but not all) of the randomly selected services Dr Perkoulidis had generated an Enhanced Primary Care (EPC) referral form to refer the patient to an allied health provider. It was rare that he would do anything more than generate the form, such as preparing a referral letter to the allied health provider to explain why the patient was attending and give sometimes critical information about the patient’s health condition. In not one of the cases reviewed was there evidence of collaboration with another provider. Indeed, it was quite clear that there had been no collaboration in most cases, as the collaborating provider was not even specifically identified. There was never any two-way communication about patients’ actual healthcare needs. In no case was a team of at least three members identified. An actual document that purported to be a TCA was created in only three of the randomly sampled services. Thus the Committee concluded Dr Perkoulidis habitually claimed this item for doing no more than generating an EPC form.
In relation to the MBS item 732 services, the Committee found that the services did not meet the MBS requirements for this item and an adequate record of the services had not been made. There was not a single example, among the 30 randomly selected services, of there being either evidence of a review of a previous plan (indeed, the GPMP and TCA template documents that appeared in the notes had no clinical information to indicate how a review would be possible), or of Dr Perkoulidis creating an amended document. In some cases there was also no earlier GPMP or TCA document that could have been reviewed by Dr Perkoulidis in a MBS item 732 review.
In relation to the MBS item 900 services, the Committee found in only 5 of 30 of the reviewed services evidence of a referral of patients to a pharmacist. Each referral letter contained only information that had been automatically populated from the medical records (and not always even including a reliable list of current medications). No written action plan was created for any reviewed MBS item 900 service. Only a blank, template document, with no actual customisation, had been created. The Committee accordingly found that Dr Perkoulidis’s clinical input into billing this item was negligible, if not non-existent.
In relation to the MBS item 2713 services, the Committee found that Dr Perkoulidis did not create adequate and contemporaneous records for the reviewed services. There were often simply no notes created to support the billing of this item. When notes were created, they were unacceptably brief and did not substantiate that he had provided any clinical input in connection with the services. Some or all of the tasks listed in the descriptor (including taking any relevant history, identifying the presenting problem of patients, providing treatment and advice, referral for other services or treatments and documenting the outcome of consultations) were not undertaken or documented by Dr Perkoulidis. The Committee also found that, in connection with these services, he did not provide adequate clinical input in relation to the prescribing and management of patients’ medications.
In relation to the MBS item 13939 services, the Committee found that the services did not meet the MBS requirements for this item. In none of the reviewed services was there evidence that Dr Perkoulidis introduced a cytoxic agent by means of an implanted pump or reservoir, as required by the item descriptor. For almost all cases, the records instead suggested that a hormone agonist was injected. Adequate records to support the billing of this item were also not made.
For foreign body removal items (MBS items 30064, 30067, 30219, 32174, 41500, 41677 and 42644), there was scant or no evidence that Dr Perkoulidis actually provided any clinical input in connection with these services. Dr Perkoulidis billed a statistically inexplicable volume of these services, being at extreme variance to all other practitioners active under Medicare during the 12-month review period.
For many services, the Committee found that there was no record that would substantiate that any work was provided in connection with these procedural services. In the alternative, if the procedures were actually performed, the Committee found that the records relating to the services were manifestly inadequate by failing to record important aspects of history and examination findings, and details of the procedures themselves and their follow up. The Committee also was concerned, if any of the services actually occurred, as to why Dr Perkoulidis had provided them at all. A number of the foreign bodies were purportedly in patients’ hands or feet where operating is complicated by a lot of tendons, muscles, veins and arteries, and the risk of damage to some other part of these areas is great. The Committee could not fathom why Dr Perkoulidis, practising in a major metropolitan area, would perform procedures better suited to surgery.
For example, for MBS item 30064 (pertaining to subcutaneous foreign body removal services), removing a foreign body from the deep tissue is a significant procedure with potentially significant complications. Dr Perkoulidis did not tend to record any follow up arrangements and indeed there was no pattern of patients returning for a review of the wound (and when patients were seen again in a short space of time, there was no mention of the procedure in the records). Although that is consistent with the procedures not having actually been performed, the Committee was very concerned that if the procedures were actually performed the patients were not adequately cared for with appropriate follow up. Many of the MBS item 30064 procedures, if they had been actually performed, would also have been better suited to treatment by a surgeon.
Dr Perkoulidis billed item 41677 some 430 times in the 12-month review period, and worked 228 days during that period. He therefore claimed to have cauterised an active nasal haemorrhage nearly twice a day on average. The Committee doubted that any of the reviewed MBS item 41677 procedures were actually performed and expressed concern that a number of patients were purportedly given nasal cautery a number of times in the review period – that is, they purportedly attended several times with nose bleeds – and there was no evidence of any attempt by Dr Perkoulidis to discover and address the cause of the problem. No meaningful clinical information was recorded in connection with the billing of this item – such as histories of nosebleeds, their severity and precipitating causes, or whether noses were actively bleeding when patients presented. Cauterisation procedures and follow up arrangements were not described, and there was no attempt to explore the causes of nosebleeds.
For MBS item 42644 (removal of foreign body in cornea or sclera), Dr Perkoulidis also billed an unusual volume of this item. In addition to expressing doubt as to whether these procedures were actually performed, as with other procedural items the Committee found the medical records manifestly inadequate. Typically, the pertinent parts of the record were limited to something like ‘right corneal foreign body; right removal of foreign body from eye’ with no mention of the history, examination findings, procedure or follow up. On the rare occasion that some history was recorded, it was a very brief description that did not account for how a foreign body came to be embedded in the cornea. The Committee was also concerned that it was not Dr Perkoulidis’s usual practice to test the patient’s vision before and after purported removals of foreign bodies, and to invert the eyelid to try to detect whether any other foreign bodies were present.
Additionally, it was noted that for a number of foreign body removal services, Dr Perkoulidis’s justifications for billing these items – such as fish bone, wind, garden and splinter related injuries, each of which were recorded an unusual number of times, or explanations in oral evidence that patients had sustained repeated foreign bodies because they were extraordinarily unlucky – did not appear genuine.
The Committee also found that Dr Perkoulidis had a fabricated a large volume of clinical records that related to the services under review, often where there was otherwise no record relating to those services. That fabrication had occurred at times coinciding with a requirement to produce medical records. The Committee found that those fabricated entries were neither contemporaneous nor genuine and thus not reflective of the services to which they purportedly related.
Although MBS items 53 and 54 were not under separate review, Dr Perkoulidis also routinely added on one of these items to a service, whether or not any work was actually done in connection with either consultation item.
The Determining Authority’s repayment direction of $392,154.60 represents the whole of the benefits that were paid for MBS items 707, 721, 723, 732, 900, 2713, 13939, 30064, 30067, 30219, 32174, 41500, 41677 and 42644. Together with the two disqualification directions, the Determining Authority considered that these directions were commensurate with the extent of the very concerning inappropriate practice found by the Committee. Dr Perkoulidis will also receive a reprimand and counselling from the Director.
On 3 August 2017, the Determining Authority also made directions in respect of a general practitioner. The practitioner was directed to repay $280,693.56 to the Commonwealth. These directions followed from a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice for all services he rendered as MBS items 721, 732, 30195 and 31265.
MBS items 721 (GP Management Plans – GPMPs) and 732 (review of a GPMP or Team Care Arrangement)
In relation to MBS item 721, the practitioner rendered this item solely in respect of chronic skin conditions, irrespective of whether he was a patient’s usual GP or if they had other chronic healthcare needs that required attention. For the patients who were provided with the reviewed services, it was not the practitioner’s intention to provide any services other than skin-related services.
The practitioner gave evidence that if he had been or was intending to see a patient regularly in respect of a chronic skin condition, he was entitled to prepare a GPMP for the patient solely in respect of that condition. This was so even if patients had other chronic healthcare needs that required attention or he was not their usual GP. In the reviewed services, the practitioner’s involvement was not such that he was patients’ usual GP who managed all of his patients’ healthcare needs. Rather, he was managing only their skin care related conditions, a narrow subset of his patients’ healthcare needs. He expected patients with non-skin-related chronic or acute conditions to attend other GPs for those conditions.
A GPMP can only be billed once in a 12-month period, and should be a comprehensive plan that addresses all of a patient’s chronic healthcare needs. For the patients to whom the practitioner had rendered GPMPs, another GP would be precluded from rendering a comprehensive GPMP covering all of their healthcare needs and goals until the expiry of the 12-month period. The practitioner’s conduct therefore precluded patients’ regular GPs from preparing comprehensive GPMPs that addressed all of his patients’ healthcare needs.
The Committee found that this conduct meant that the GPMPs were not comprehensive and failed to appropriately address patients’ chronic healthcare. By example, for one patient, the practitioner prepared a GPMP only in relation to non-melanoma skin cancer. However, the patient also had Parkinson’s disease and hypertension (and perhaps other conditions that the practitioner did not inquire about) that were not addressed.
The content recorded in GPMPs was also inadequate. For example, one GPMP documented that a patient had malignant melanoma, but did not record the anatomical location of the melanoma. In general, information regarding a patient’s aims and goals was also lacking.
The content of the care plans was therefore what would be expected of a normal consultation for melanoma or skin cancer, rather than a comprehensive GPMP addressing all of a patient’s chronic healthcare needs.
The Committee found that the practitioner engaged in inappropriate practice in rendering MBS item 732 for substantially the same reasons that it found he engaged in inappropriate practice in his rendering of MBS item 721.
MBS item 30195 (treatment of relevant benign skin neoplasms)
The practitioner failed to keep adequate records in connection with MBS item 30195. The practitioner relied on recording detail in his billing record rather than the clinical record of each patient. The Committee considered, in the circumstances of this case, that other practitioners would be unlikely to refer to the billing record to look for essential clinical information that should have been included in the clinical notes.
For all services, the practitioner did not record the location of lesions or specify the method of removal of each lesion in his clinical records, which the Committee found to be unacceptable.
MBS item 31265 (treatment of relevant basal or squamous cell carcinoma)
For MBS item 31265, the Committee found that the practitioner did not keep an adequate record of to some or all of the following in the entries for these services:
b) the size of lesions;
c) local anaesthetic;
d) the method of lesion removal;
e) method of wound closure;
f) the excision margin;
g) the suture material;
h) the number of sutures; and
i) post-operative wound care advice given.
By example, in respect of one MBS item 31265 service the practitioner’s entry indicated only that he had excised a BCC from a particular anatomical site, and noted the printing of a histopathology form.
The failure to record the abovementioned information in the entries for each service was found to be unacceptable.
Determining Authority determination
The Determining Authority’s repayment direction of $469,339.90 represents the whole of the benefits that were paid for MBS items 721, 732 and 31265 services, and 50% of the benefits paid for MBS item 30195 services. The practitioner was also reprimanded and a counselling direction was made.
C. Federal Court
One judicial review application was heard by the Federal Court in September 2017. The decision has been reserved.
D. Referrals to the major non-compliance (fraud) division
No matters were referred to the major non-compliance (fraud) division in September 2017.
E. Referrals to AHPRA
One matter was referred to AHPRA in September 2017 for noncompliance with professional standards.