PSR Director's Update for March 2020

Published date

16 April 2020

A. Directors Section 92 agreements effective in March 2020

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 medical practitioner

During the review period, the practitioner billed over 16,000 services to fewer than 5,000 patients and rendered more days of 60 to 79 professional attendances than at least 99 percent of their peers. The Director reviewed this practitioner’s rendering of Medicare Benefits Schedule (MBS) items 54, 57, 95, 96, 721, 723, 2713, 2715, 5040, 5060, 30029, 30186, 30207, 30219, 31362, 31364, 31366, 31368 and 31370, and Pharmaceutical Benefits Scheme (PBS) items 3119E and 8254K. The Director had persisting concerns that:

the MBS requirements were not always met, including the minimum time requirement outlined in the MBS item descriptor for MBS items 54, 57, 95, 96, 2713, 2715, 5040 and 5060;
where either MBS items 721 or 2715 were billed, the documentation was not individualised or was irrelevant to patient conditions and the descriptor requirement for MBS item 723 was not always met as there was often no evidence of two way communication with two other healthcare providers;
the therapeutic procedures provided by the practitioner were not always clinically indicated and the MBS requirements were not always met;
the practitioner did not maintain adequate records; and
there was not always a clear clinical indication for prescribing antibiotics and PBS item 8254K was prescribed outside of PBS restrictions.

The Director noted the practitioner made a Voluntary acknowledgement of incorrect payments to the Department of Health.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern .The practitioner agreed to repay $240,000, to be disqualified from providing MBS items 57, 95, 96, 723, 2713, 2715, 5040, 5060, 30029, 30186, 30207, 30219, 31362, 31364, 31366, 31368 and 31370 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period the practitioner provided 70 to 79 professional attendances per day on more than 15 occasions which was in excess of 99 percent of their peers and billed MBS item 721 in excess of 98 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723 and 732, and prescribing of antibiotics under the PBS. The Director had persisting concerns that:

MBS requirements were not always met and the records for MBS item 36 often contained insufficient clinical input to justify the minimum time requirement outlined in the MBS item descriptor;
where chronic disease management services (MBS items 721, 723 and 732) were billed, the documentation was not sufficiently individualised to the patient or occasionally the documentation was incomplete. For MBS item 723 there was often no evidence of two way communication with two other healthcare providers;
the practitioner did not maintain adequate records; and
there was not always a clear clinical indication for prescribing antibiotics and PBS item 8254K was prescribed outside of PBS restrictions.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $320,000, to be disqualified from providing MBS items 36, 721, 723 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period the practitioner rendered more than 15,000 services which was in excess of 99 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 707, 721, 723, 732, 2713 and 5020, and had no concerns in relation to MBS items 23 and 5020. The Director had persisting concerns in relation to the remaining items that:

MBS requirements were not always met. In particular the records for MBS items 36, 707 and 2713 often contained insufficient clinical input to justify the minimum time requirement outlined in the respective MBS item descriptor;
where MBS items 707, 721 and 723 were billed, the documentation was not always individualised, comprehensive and often contained inaccurate information;
the requirements for chronic disease management services were not always met as the practitioner appeared to provide these services to patients who did not have a suitable chronic disease. Where MBS item 723 was billed, there was often no evidence of two way collaboration with two other healthcare providers;
the practitioner did not maintain adequate records;
not all services were clinically indicated; and
the practitioner did not always provide adequate clinical input into each service.

The Director noted the practitioner made a Voluntary acknowledgement of incorrect payments to the Department of Health.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $90,000, to be disqualified from providing MBS items 707 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner was assigned to the 99th percentile for MBS items 721, 723, 10997 and 11506, amongst other MBS items. The Director reviewed this practitioner’s rendering of MBS items 36, 721, 723, 732, 10997, 11506, 11700, 56001, 56223, 56501, 56507 and 57341, and PBS item 8254K, and had no concerns in relation to MBS items 11700, 56001, 56223, 56501, 56507 and 57341, and PBS item 8254K. The Director had persisting concerns that:

the practitioner did not maintain adequate records for all MBS items;
MBS requirements were not always met and the records for MBS item 36 often contained insufficient clinical input to justify the minimum time requirement outlined in the MBS item descriptor;
the descriptor requirements for chronic disease management services were not always met as patients did not appear to have a suitable chronic disease and for MBS item 723 there was often no evidence of two way collaboration with two other healthcare providers. Further, the documentation was not always sufficiently individualised to the patient. The practitioner’s reviews for MBS item 732, were not always adequately meaningful and did not always rectify the deficiencies of the original documentation;
MBS item 10997 appeared to be billed where a nurse prepared the GP Management Plan (GPMP) or Team Care Arrangement (TCA) rather than performing a service consistent with an established GPMP, TCA or multidisciplinary care plan; and
MBS item 11506 services were not all clinically indicated or the clinical indication was not adequately recorded.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $180,000, and will be reprimanded by the Director.

An agreement with a general practitioner

During the review period, the practitioner provided more days of 70 to 89 professional attendances than at least 99 percent of their peers and more days of 60 to 69 professional attendances than at least 98 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 721, 723 and 732. The Director had persisting concerns that:

the medical records were inadequate across all items, particularly due to the brevity of records;
the records for MBS item 36 often contained insufficient clinical input to justify the minimum time requirement outlined in the MBS item descriptor;
where MBS items 721 and 723 were billed, the documentation did not relate to a chronic condition as required by the MBS descriptors and not all services were clinically indicated. The requirements for MBS item 723 were not always met as there was often no evidence of two way communication with two other healthcare providers;
the documentation was often not individualised to patients and there was not always adequate clinical input into the preparation of the GPMP and TCA from the practitioner;
for MBS item 732 not all matters in the original GPMP and TCA were reviewed and the deficiencies of original documentation was not always rectified.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $260,000, to be disqualified from providing MBS items 721, 723 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner

The practitioner billed MBS item 5020 on more than 7,000 occasions and MBS item 5040 on more than 750 occasions, which was in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 5020, 5040, 11700, 63551, 63554 and 63560, and had no concerns in relation to MBS items 23 and 5020. The Director had persisting concerns in relation to the remaining items that:

the medical records were inadequate;
MBS requirements were not always met including the minimum time requirements for MBS item 5040;
the diagnostic imaging services were not always clinically indicated; and
the practitioner did not always provide adequate clinical input into each service.

The Director noted the practitioner made a Voluntary acknowledgement of incorrect payments to the Department of Health.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $21,275.20 and will be reprimanded by the Director.

An agreement with a medical practitioner

During the review period the practitioner billed MBS items 591 and 594 more than 99 percent of their peers and billed MBS item 599 more than 98 percent of their peers. The Director reviewed this practitioner’s rendering of MBS items 591, 594, 597 and 599. The Director had persisting concerns that:

MBS requirements for MBS items 591, 594, 597 and 599 were not always met, as the patients did not always require urgent treatment or assessment;
the practitioner did not always provide adequate clinical input into each service; and
the medical records were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $140,000 and will be reprimanded by the Director.

B. PSR Committee final determinations

One final determination became effective in March 2020.

PSR Committee No. 1060

On 4 March 2020, a final determination came into effect concerning Dr Chris Pepulani who practised in Cannington, Western Australia during the year under review. The practitioner was directed to be reprimanded, directed to repay $434,331 to the Commonwealth. The practitioner was also directed to be disqualified from MBS items 36 and 44 for a period of three months and directed to be disqualified from MBS items 721,723, 732, 2506, 2507, 2525 and 2558 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 rendered as MBS items 23, 36, 44, 721, 723, 732, 2506, 2507, 2525 and 2558 and PBS items 3162K and 8582Q.

The Committee’s specific findings for each of the referred services were for the following reasons:

In relation to MBS items 23, 36 and 44, the Committee found, variously, that:

the MBS requirements were not met;
the clinical input was inadequate;
the progress note for the consultation did not reflect a consultation of sufficient complexity to warrant the item being billed; and
the notes did not record important clinical information and another practitioner could not effectively take over care of the patient based on the information in the patient record.

In relation to MBS item 721, the Committee found, variously, that:

the records of GPMPs were largely template driven;
a number of chronic disease management documents were not up to date and omitted critical patient health information;
the MBS item requirements were not met; and
the service was not clinically indicated.

In relation to MBS item 723, the Committee found, variously, that:

TCA documents were generic;
the MBS item requirements were not met; and
the medical record was inadequate.

In relation to MBS item 732, the Committee found, variously, that:

GPMP and TCA review documents were generic; and
the MBS item requirements were not met.

In relation to MBS item 2506, the Committee found, variously, that:

the MBS item requirements were not met as the services did not take place at a location other than consultation rooms.

In relation to MBS item 2507, the Committee found, variously, that:

none of the MBS item 2507 services rendered in the review period met the MBS requirements;
item 2507 was regularly billed in association with another consultation in circumstances where the practitioner was not entitled to bill that separate consultation; and
there was inadequate clinical input into item 2507 consultations.

In relation to MBS item 2525, the Committee found, variously, that:

the diabetes cycle of care documents were template driven;
the service did not meet the MBS item requirements; and
there was inadequate clinical input into the service.

In relation to MBS item 2558, the Committee found, variously, that:

the MBS item requirements were not met;
the asthma cycle of care documents were template driven; and
there was inadequate clinical input into the service.

In relation to MBS item 3162K and 8582Q, the Committee found, variously, that:

clinical input in relation to the management of prescribing diazepam and tramadol to patients was inadequate; and
in all cases the medical record was inadequate.

C. Federal Court

National Home Doctor Service Pty Ltd v Director of PSR [2020] FCA 386

The Federal Court set aside the decision of the Director of Professional Services Review (PSR) to refer National Home Doctor Service Pty Ltd (NHDS) to a PSR Committee for investigation, but indicated that it remains open for the Director to do so again.

A number of medical practitioners had previously been referred to PSR and 14 practitioners had acknowledged that they had engaged in inappropriate practice in connection with rendering urgent after-hours MBS items while associated with NHDS. The nature of the conduct identified as raising a concern about inappropriate practice included clinical decision-making in prescribing antibiotics and schedule 4 and 8 medications, poor clinical input, inadequate record-keeping, and a concern that a large proportion of the services rendered involved conditions that either did not require treatment or could have reasonably waited until the next in-hours period.

The Court said that the Director was entitled to have regard to those practitioners’ conduct when referring NHDS to a PSR Committee to investigate whether NHDS engaged in inappropriate practice through the provision of urgent after-hours services by a further 56 practitioners.

The Court said that it was not unreasonable or irrational for the Director to have made that referral. However, the Court said that, before doing so, the Director should have provided NHDS with more information specific to the practitioners’ conduct and their relationship with NHDS that caused the Director concern so that NHDS would have had an opportunity to make submissions to dissuade the Director from referring the services of the 56 practitioners to a PSR Committee.

The Court upheld the PSR’s position that the Director did not need to make a positive finding concerning the legal relationship between NHDS and the practitioners, but merely have a concern that such a relationship may have existed, that the practitioners may have engaged in inappropriate practice in providing services, and that NHDS may have knowingly, recklessly or negligently caused or permitted a practitioner to engage in inappropriate practice.

The judgment can be accessed here.

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

One matter was referred to the major non-compliance (fraud) division in March 2020.

E. Referrals to AHPRA (106XA/B)

Six matters were referred to AHPRA in March 2020.