PSR Director's Update for November 2017

A. Director’s Section 92 agreements effective in November 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 23, 35, 36, 43, 51, 705, 707, 721, 723, 732, 903, 2715, 5020, 5028, 5040, 5049, 5067, 56223 and 66596 and PBS item 2622B was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items, except for MBS items 35, 903 and 5028, in relation to which the Director had no concerns. The practitioner agreed to repay $650,000 and will be reprimanded by the Director.
• An agreement with a medical practitioner practising in general medicine. This practitioner’s rendering of MBS items 160, 721, 723 and 732 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 $100,000 and will be reprimanded by the Director.
• An agreement with a general practitioner whose rendering of MBS items 23, 36, 597, 599 and 2715 and provision of a prescribed pattern of services (the 80/20 rule) was reviewed by the Director. The practitioner acknowledged they rendered a prescribed pattern of services and that they engaged in inappropriate practice in connection with providing all of these items save for MBS item 23, in relation to which the Director had no concerns. 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 23, 36, 5020, 5040, 701, 2713, 18232, 31270, 31275, 31285, 31290, 31330 and 45203 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 31330, in relation to which the Director had no concerns. The practitioner agreed to repay $480,000 and will be reprimanded by the Director.
• An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 721, 723, 2717, 11700, 66596, 66833 and 66839 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 $600,000 and will be reprimanded by the Director.
• An agreement with a general practitioner. This practitioner’s rendering of MBS items 23, 36, 2712, 2713, 2715, 2721, 66716, 56301, and 56307 and PBS items 3162K and 9202H was reviewed by the Director. The practitioner acknowledged they engaged in inappropriate practice in connection with providing all of these items, except for MBS items 56301 and 56307 and PBS item 9202H, in relation to which the Director had no concerns. The practitioner agreed to repay $260,000, will be disqualified for 12 months from rendering MBS item 2721 services and will be reprimanded by the Director.
• An agreement with a general practitioner. This practitioner’s rendering of MBS items 721, 723, 732 and 2713 and PBS items 3162K, 3133X, 2089Y, 2363J, 8525Q, 8611F, 2723H, 8785J, 2355Y and 1654C 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 $20,000, will be disqualified from prescribing or dispensing under the PBS for three months and will be reprimanded by the Director.
• An agreement with a general practitioner. This practitioner’s rendering of MBS items 44, 721, 723, 732, 2525, 2712, 2713, 2715 and 2717 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 $230,000 and will be reprimanded by the Director.

B. PSR Committees’ final determinations effective in November 2017

On 13 October 2017, the Determining Authority made final determinations in respect of four general practitioners, each of which became effective this month.

PUR 894

This general practitioner was directed to repay $162,311.23 to the Commonwealth and will receive counselling and a reprimand from the Director.  These directions followed from a final report of a PSR Committee which concluded the practitioner engaged in inappropriate practice for services he rendered as MBS items 36, 723, 597, 30064, 47018, 47303, 47312, 47336, 47339, 47363, 47636, 47663, 66602, 66608 and 66716 during the review period.

For MBS item 36 services (Level C consultations), the Committee found that the practitioner’s clinical decision-making was not appropriate, the services that he rendered did not meet the requirements of the MBS item descriptor and/or he did not keep an adequate record of the consultation.

The Committee also made findings of a similar nature in respect of MBS item 723 (team care arrangements). It found that inaccurate records were kept and that the requirements of the MBS were not met or poorly documented. In particular, the requirement to engage and/or appropriately document the engagement of at least two collaborating providers, each of whom provide a different kind of treatment or service in connection with each team care arrangement, was not met. Important clinical information was also absent from TCAs, which meant that they were not comprehensive documents for the treatment of patient’s chronic conditions.

The Committee’s findings about MBS item 597 (urgent consultations during a sociable after hours period) centred on the practitioner’s failure to record adequate clinical detail in relation to the consultations, his rendering of services as this item in circumstances where the patient did not actually require urgent treatment, and his failure to provide adequate clinical input during these consultations. For some cases, the Committee also considered that the practitioner did not have to return to his practice specifically to open his consultation rooms for the purposes of rendering an MBS item 597 service, which is a requirement for this item if the services are rendered at consulting rooms. Important clinical information was not always recorded in connection with services rendered as this item.

The Committee’s findings about MBS item 30064 (removal of subcutaneous foreign bodies) included clinical concerns (for example, one procedure involved the removal of deep foreign bodies where adrenaline should have but was not used), and that insufficient detail was recorded in relation to procedures or how foreign bodies came to be lodged in patients’ bodies. For some services, the Committee found that the practitioner did not keep any records at all in connection with the services.

For MBS item 47018 (treatment of dislocated elbow by closed reduction), the Committee found that the practitioner inappropriately billed this item for the treatment of anatomical areas that were not the elbow, or for injuries that did not require treatment by closed reduction. For example, one young patient had ‘slight dorsal tilting’, which the Committee found could be simply protected and allowed to grow out in a patient of that age, and accordingly did not require closed reduction treatment. Similar findings were made in respect of MBS items 47303, 47312, 47336, 47339, 47363, 47636 and 47663.

In relation to MBS item 66602 (initiation of serum vitamin B12 tests), the Committee found inappropriate practice where this test was initiated without supporting clinical indications, where adequate clinical records were not kept (for example, where the results of tests, details of patients’ presenting complaints or any clear rationale for initiating a vitamin B12 test were not adequately documented), and/or where adequate clinical input was not provided (for example, where the practitioner did not take adequate histories or examinations). Similar findings were made in relation to MBS items 66608 (the item for vitamin D tests during the review period) and 66716 (thyroid-stimulating hormone quantitation).

The repayment direction of $162,311.23 by the Determining Authority represents the total benefits that were paid for MBS item 36, 723, 597, 30064, 47018, 47303, 47312, 47336, 47339, 47363, 47636 and 47663 services in connection with which findings of inappropriate practice were made.

PUR 903

This general practitioner was directed to repay $1,377.43 (excluding some money already voluntarily repaid) to the Commonwealth and will receive counselling and a reprimand from the Director. These directions followed from a final report of a PSR Committee which concluded the practitioner engaged in inappropriate practice in connection with rendering the following skin procedure services:

• four services as MBS item 31235;
• three services as MBS item 31265; and
• four services as MBS item 31310.

The Committee found that the practitioner engaged in inappropriate practice in connection with all of these items because the requirements of the relevant MBS item were not met, his clinical input was poor and/or the record was inadequate. The reasons for these findings included that:

• Wounds were closed with flaps rather than considering other options such as leaving the wound open until pathology results were known, given that the practitioner was fairly certain that the patient would need further, more extensive excisions that would also require flap closure.
• Insufficient detail was recorded by the practitioner to determine which lesions were excised, and images in Molemax records and written records did not agree as to the location of lesions.
• The location of an excised lesion was not at the anatomical site prescribed by the relevant item descriptor.
• The record for one service did not indicate the nature of a wound closure other than the suture material used. In such a case, the clinical record should have at least identified the nature and detail of the type of wound closure.
• The practitioner billed MBS item 31310 in connection with flap procedures that were not double advancement flaps as contemplated by the item descriptor.

The repayment amount represents the full benefits that were paid for the eleven services in relation to which findings of inappropriate practice were made. 

As the findings were limited to three or four services for each MBS item, the sampling methodology determination applied by the Committee dictated that the Committee’s findings of inappropriate practice were too small to extrapolate to the entire class of services rendered as each item. That means any repayment amount sought by the Determining Authority could not exceed the benefits paid for each of the three or four services rendered as each item.

PUR 917

This general practitioner was directed to repay $366,734.71 to the Commonwealth and will receive counselling and a reprimand from the Director. These directions followed from a final report of a PSR Committee which concluded the practitioner engaged in inappropriate practice in connection with rendering MBS items 36, 31255, 31265, 31270, 31280 and 31285.

For MBS item 36, the Committee found that the practitioner’s clinical input or clinical recordkeeping in connection with these services was inadequate. The records that were kept for these consultations did not include, as relevant, sufficient history, examination findings, management plans, and preventative health care advice.

For MBS item 31280 (a skin excision item during the review period), the Committee found that the practitioner failed to provide adequate clinical input, comply with the MBS requirements and keep adequate records. For example, the practitioner did not describe in his records lesions, wound closure, patients’ comorbidities or other issues affecting the procedures, relevant medications, relevant histories of wound infections, or any history relating to the usage of local anaesthetic. In some circumstances, the practitioner billed pre‑procedural and post-procedural work as independent consultation items where a procedural item was also billed. The Committee found it was inappropriate to bill a consultation item in these circumstances given there was no discrete clinical content to justify billing the consultation item, as all work towards the procedure was part of the procedural service.

The Committee also made findings of inappropriate practice in respect of the practitioner’s rendering of MBS items 31255, 31265, 31270 and 31285 (each of which were procedural services during the review period) because the practitioner did not keep adequate and contemporaneous records in connection with these services.

PUR 945

This general practitioner was directed to repay $70,227.86 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 the practitioner engaged in inappropriate practice in connection with rendering MBS item 721, 723, 732, 11506, 11610, 11700 and 30202 services. The Committee’s findings were driven largely by the practitioner’s recordkeeping. The records were often missing important clinical information to enable another practitioner to effectively undertake ongoing care of her patients.

For MBS item 721 services, the Committee found that GP management plans were not closely tailored to each particular patient’s healthcare needs or did not make it apparent to the patient what was required of him or her, and/or it was not an appropriate time to prepare a plan due to either the patient’s acute symptomatology or because the results of important investigations that would have had a significant bearing on the treatment plan were not yet known. Goals were often expressed generically, such as ‘improve mood’, without a baseline assessment of a patient’s mood, a specific target for the patient to achieve or any indication of the action to be taken by the patient other than to engage with allied health providers.

Findings of inappropriate practice were made in relation to some team care arrangements (MBS item 723), either because of a failure to comply with the requirements concerning the engagement of collaborating providers or due to the plan being of a poor quality.

For MBS item 732 (review of a GP management plan or team care arrangement), the Committee found the practitioner engaged in inappropriate practice because the service was claimed erroneously or in substitution for MBS items 721 and 723, or that, because the original plans under review lacked specific goals and baselines, the reviews were somewhat superficial and much of the patient’s progress was left to a subjective impression on the date the service was rendered.

For MBS item 11506 (spirometry), the correct usage of this item requires three acceptable tests. Most of the services reviewed by the Committee did not have three results before and three results after the inhalation of bronchodilator displayed. The medical records were also inadequate for this item because it was unclear what respiratory history or examination findings caused the practitioner to perform spirometry, or what the practitioner had made of the result, which made it unclear how the result of the spirometry affected the patient’s management.

For MBS item 11610 (ankle brachial index tests), the Committee found that the practitioner did not measure bilateral leg pulses, but rather only measured one leg. This is not compliant with the item descriptor, and also of clinical concern given that the Committee considered measuring both legs is necessary to ensure the accuracy of an ankle brachial index test. The Committee also found that the clinical indications for performing ankle brachial index tests were not always recorded or that it would be difficult for another doctor relying on the record to understand why the practitioner was sufficiently concerned about peripheral vascular disease to perform an ankle brachial index test.

For MBS item 11700 (electrocardiography), the Committee’s findings of inappropriate practice primarily related to the practitioner’s rendering of this item in circumstances where it was not clinically relevant or where the clinical indication could not be inferred from the record due to the absence of pertinent history and examination findings.

In relation to MBS item 30202 (removal of a malignant neoplasm or mucous membrane by means of a liquid nitrogen cryotherapy procedure), the Committee made a number of findings of inappropriate practice for reasons that included inadequate records and where histopathology reports did not confirm malignancy.

The direction to repay $70,227.86 represents all of the benefits that were paid for services that were found to be rendered inappropriately. 

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 November 2017.

E. Referrals to AHPRA

Two matters were referred to AHPRA in November 2017 in relation to two practitioners who endangered the life or health of their patients.