PSR Director's Update for June 2020

A. Directors Section 92 agreements effective in June 2020

An agreement with an oncologist

During the review period the practitioner billed more than 19,000 Medicare Benefit Schedule (MBS) services. The Director reviewed this practitioner’s provision of MBS items 112, 116, 13915, 13918, 13921, 13924, 13945 and 14221. The Director had no significant persisting concerns in relation to MBS items 13915, 13921 and 14221. The Director had persisting concerns in relation to the remaining items that:

• the practitioner often billed consultation services in association with chemotherapy and/or line access items. In those circumstances, there was often insufficient documentation of a separate consultation that would justify the billing of MBS items 112 or 116;
• medical records were inadequate. At times, there was no record that the service had been provided by the practitioner;
• MBS item 112 was rendered in circumstances where the patient may not have been eligible for the service; and
• the MBS requirements were not always met. MBS item 13924 appeared to have been billed for subsequent days of treatment where the same infusor was running and MBS item 13945 appeared to have been billed for de-accessing the drug delivery device.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $135,000, to be disqualified from providing MBS item 13924 for 12 months, and will be reprimanded by the Director.

An agreement with a nurse practitioner

During the review period, the practitioner rendered longer duration attendance services at a variance to all nurse practitioners. The Director reviewed this practitioner’s provision of MBS items 66596, 66716, 82210 and 82215, and Pharmaceutical Benefit Scheme (PBS) items 1891M, 3119E and 8254K. The Director had no significant persisting concerns in relation to MBS item 66716. The Director had persisting concerns in relation to the remaining items that:

• the MBS requirements were not always met, including the minimum time requirements (where relevant);
• the practitioner’s initiation of pathology was not always clinically indicated;
• records were inadequate;
• the practitioner prescribed antibiotics where there was no documented clinical indication; and
• the practitioner prescribed PBS items 1891M and 8254K outside the PBS restrictions.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $85,000 and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period, the practitioner billed MBS items 160, 705, 732 and 5040 in excess of 98 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 160, 705, 732, 5020 and 5040, MBS item 10997 services rendered on the practitioner’s behalf, and prescribing of PBS item 8254K. The Director had persisting concerns that:

• MBS and PBS restrictions were not always met. For example MBS item 160 was billed in circumstances where it did not always appear that the patient was in imminent danger of death or that the practitioner spent between one and two hours with the patient;
• records were inadequate; and
• the practitioner did not always provide sufficient 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 $400,000, to be disqualified from billing MBS items 705, 732, 5040, 160 and 10997 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period the practitioner rendered more than 60 professional attendances on more than 30 days, which was in excess of 99 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 53, 54, 57, 160, 161, 707, 721, 723, 732, 900, 2713, 2717, 5040, 30185, 30186, 66596, 66722, 66734 and 73805, MBS item 10987 and 10997 services rendered on the practitioner’s behalf and prescribing of PBS items 8254K and 9048F. The Director had persisting concerns that:

• the practitioner did not always keep adequate medical records;
• MBS item requirements (including where there were minimum time requirements and where MBS items were billed in association) were not always met;
• the practitioner did not always provide adequate clinical input into services;
• services were not always clinically indicated. In particular, pathology appeared to often be initiated as part of a standard battery of tests rather than as a result of clinical indication; and
• the practitioner prescribed PBS medications outside of the PBS restrictions and without appropriate clinical indication being documented.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $415,000, to be disqualified from billing MBS items 57, 161, 721, 723, 732, 900, 2717, 10997, 30192, 66722 and 73805 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period the practitioner billed more than 14,000 services. The Director reviewed this practitioner’s rendering of MBS items 23, 52, 721 and 723, and prescribing of PBS items 7530H and 8601Q. The Director had no significant persisting concerns in relation to MBS item 52. The Director had persisting concerns in relation to the remaining items that:

• MBS requirements were not always met. For example the practitioner billed MBS item 23 for services where they did not record a clinically relevant patient history or examination;
• the practitioner did not always maintain adequate records;
• the practitioner did not always provide adequate clinical input into each service;
• some medications were prescribed without clinical indication; and
• PBS item 8601Q was prescribed to patients that may not have had symptoms that were inadequately controlled using a standard dose proton pump inhibitor.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $160,000, to be disqualified from providing MBS items 721 and 723 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period the practitioner billed MBS items 721 and 723 in excess of 99 percent of their peers. The Director reviewed this practitioner’s provision of MBS items 23, 36, 721, 723, 5040, 66560 and 69333, MBS item 10997 services rendered on the practitioner’s behalf, and prescribing of PBS item 5457F. The Director has no significant persisting concerns in relation to MBS items 23 and 66560 and PBS item 5457F. The Director had persisting concerns in relation to the remaining items that:

• MBS requirements were not always met, including the minimum time requirements (where relevant);
• the practitioner did not always maintain adequate records; and
• some services were rendered or initiated without clinical indication. In particular, pathology appeared to often be initiated as part of a standard battery of tests rather than as a result of clinical indication.

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 billing MBS items 721, 723 and 10997 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

PSR Committee No. 1106

On 15 June 2020, a final determination came into effect regarding Dr David Bertram, psychiatrist, who practised in Brighton, South Australia, during the review period.  The practitioner was directed to:

• be reprimanded,
• repay $100,000 to the Commonwealth, and
• be disqualified from billing MBS items 300, 302 and 304 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 300, 302, 304, 330 and 332. 

The Committee was concerned across all the reviewed MBS items that the practitioner failed to maintain appropriate records and their record-keeping practices were not consistent with statutory and regulatory requirements. The Committee considered the nature of the inadequate record-keeping to on its own constitute inappropriate practice.

In a high proportion of reviewed services, especially those relating to in-room services, no record was created relating to the service. It was noted that often records had not been kept for extended periods of time where patients had been regularly seen. In relation to home visit services, while there was more commonly a record of attendance made, the Committee considered the records created were not sufficient to enable another practitioner to effectively assume patient care.

In relation to consultations which have minimum time requirements, due to the lack of information in the medical records it was generally not possible to discern why longer consultations were billed and in many cases the records did not support the billing of a longer consultation item.

The Committee also outlined that the practitioner’s prescribing was not supported by appropriate documentation and in some cases the prescribing gave rise to clinical concerns as antipsychotic medications and benzodiazepines were prescribed at a greater incidence than expected.

The Determining Authority’s repayment direction of $100,000 for benefits paid as MBS items 300, 302, 304, 330, 332 along with the disqualification from 12 months from the provision of in-room services (MBS items 300, 302 and 304) reflects a balance of the Committee’s high level of findings of inappropriate practice, with the beneficial nature of the home services provided by the practitioner to a disadvantaged community. The practitioner will also receive a reprimand from the Director.

C. Federal Court

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

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

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

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in June 2020.