PSR Director's Update for April 2020

Published date

15 May 2020

A. Directors Section 92 agreements effective in April 2020

No s 92 agreements became effective in April 2020.

Due to the delayed timing of the April meeting of the Determining Authority, section 92 agreements ratified at this meeting do not become effective until May 2020. Details of these agreements will therefore be published in our May 2020 update.

B. PSR Committee final determinations

Three final determinations became effective in April 2020.

PSR Committee No. 1136

On 28 April 2020, a final determination came into effect regarding Dr Anwar Hossain, general practitioner, who practised in Prestons, New South Wales, during the review period. The practitioner was directed to be:

reprimanded and counselled,
repay $619,664.45 to the Commonwealth,
disqualified from billing MBS item 36 for a period of six months, and
disqualified from billing MBS items 721, 723, 732 and 2713 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 23, 36, 721, 723, 732 and 2713.

The Committee was concerned about the practitioner’s compliance with MBS requirements (especially in relation to chronic disease management services), the practitioner’s record-keeping and, in some instances, the practitioner’s prescribing of antibiotics outside of clinical guidelines and their clinical input into the service.

In relation to MBS item 23 and 36 services, the Committee found in a high number of cases that the practitioner’s records were inadequate as they lacked a focussed history, examination results and the details of any advice provided to the patient. Some of the MBS item 23 services appeared to be for straightforward presentations more consistent with an item 3 service and many of the MBS item 36 services suggested a level of complexity and content not in keeping with the billing of a Level C, 20 to 40 minute attendance.

MBS item 721 requires the formulation of a GP management plan (GPMP) in connection with the patient. The practitioner routinely created GPMP documents but the Committee found in all reviewed cases the MBS requirements for the item were not met. The documents created indicated the condition the plan was for, but the goals in the plan were generic and the plans listed participants in the patients care that were not intended to be engaged. The templates used were not modified to relate to the patient’s specific diagnosis and they often contained irrelevant and misleading information that obscured any information relevant to the patient.

MBS item 723 relates to the creation of a Team Care Arrangement (TCA) involving at least two other healthcare providers. The Committee found in all reviewed cases there was no adequate collaboration with other healthcare providers and no adequate documentation of any plan regarding the care or services the other providers were to provide. MBS item 732 involves the review of a GPMP or TCA. The Committee found the practitioner billed this item for normal reviews of patients’ long term conditions and the services did not involve any attempts to comply with the regulatory requirements of the item.

In relation to MBS item 2713, because of the brevity of the records and lack of particularisation of the history, assessment and management plan, the Committee considered the record disclosed insufficient clinical content to justify an attendance of at least 20 minutes, as required by the MBS item descriptor. In addition the Committee made findings on the basis the practitioner’s records for these services were inadequate as they were often only cursory notations and the Committee considered it would be difficult for another practitioner to assume patient care.

The Determining Authority’s repayment direction of $619,664.45 represents the whole of the benefits that were paid for MBS items 23, 36, 721, 723, 732 and 2713 less an amount that had already been voluntarily repaid by Dr Hossain in relation to his MBS item 36 services. Together with the disqualification directions, the Determining Authority considered that these directions were commensurate with the serious extent of inappropriate practice found by the Committee. The practitioner will also receive a reprimand and counselling from the Director.

PSR Committee No. 1089

On 29 April 2020, a final determination came into effect regarding Dr Hector Mario Urbina, general practitioner, who practised in Marsden, Queensland during the review period. The practitioner was directed to be:

reprimanded and counselled,
repay $779,878.05 to the Commonwealth,
disqualified from billing MBS item 160 for a period of six months;
disqualified from billing MBS item 36 for a period of 12 months;
disqualified from billing MBS item 721 and 723 for a period of 18 months; and
disqualified from billing MBS items 44, 2717, 30061, 30064 and 41500 for a period of 36 months.

The directions were made following a final report of a PSR Committee, which concluded that the practitioner engaged in inappropriate practice in connection with services provided as MBS items 36, 44, 160, 721, 723, 2717, 30061, 30064 and 41500.

The Committee was concerned with the highly unusual structure of the practitioner’s medical records, which it found to be incomprehensible and made it near impossible for another practitioner relying on the record to effectively take over ongoing care of his patients. The Committee was otherwise concerned with the practitioner’s inadequate record keeping, lack of clinical indication for services, clinical decision-making, and failure to comply with MBS requirements. The Committee was particularly concerned that the practitioner had rendered some services improperly or fictitiously.

In relation to MBS items 36 and 44, the Committee found services were not clinically indicated. The practitioner’s records failed to include sufficient clinical detail for another practitioner to understand with any precision what had transpired in the consultation or to support the minimum time requirements for both items. Relevant clinical content was often omitted from the record. The practitioner heavily relied on copied text from previous services, templates and auto-text entries and much of the content was irrelevant, inconsistent and often identical across patient’s records and therefore unreliable.

The Committee found the practitioner rendered services as MBS item 160, where the patient was not in imminent danger of death and/or where the practitioner had not attended the patient for at least one hour, as required by the descriptor.

For MBS items 721 and 723, the Committee found that while patients often had a chronic condition that might have justified a GP Management Plan (GPMP) or Team Care Arrangements (TCA), there was no evidence of a plan tailored for the patient in any instance. There was either no plan documented at all or, where there was a plan, it was merely a template created and automatically populated from the software with no patient-specific content recorded. There was no evidence of patient participation in the formulation of the plan. None of the TCA documents identified a collaborating provider, except coincidentally through the pasting of extensive progress notes into the document. There was no record of consultation with collaborating providers. In a majority of services, a referral did not eventuate from the plan.

MBS item 2717 requires a 40 minute attendance for the formulation of a GP mental health treatment plan. The Committee found no evidence a plan had been created in any of the services reviewed. The progress notes were otherwise inadequate, failing to document a presenting mental health complaint or results of a suitable outcome measurement tool. The clinical content that was available was rarely consistent with a service lasting at least 40 minutes.

For all services rendered as MBS items 30061, 30064 and 41500, the Committee found the practitioner did not perform a procedure involving removal of a foreign body as contemplated by the item descriptors in all instances, although accepted something else may have occurred (such as, cleaning or dressing a wound). The Committee found the practitioner did not have the requisite level of knowledge commensurate with a medical practitioner performing these services. The Committee concluded the practitioner had fictitiously or improperly billed the items and created inaccurate records to suggest that he performed procedures that never actually occurred. The Committee also found in the alternative, that the practitioner failed to make an adequate and contemporaneous record of the service performed, including identifying any foreign body, its location, the mechanism by which it came to be there, or the procedure employed for removing it.

The Determining Authority’s repayment direction of $779,878.05 represents the whole of the benefits that were paid for MBS items 36, 44, 160, 721, 723, 2717, 30061, 30064 and 41500 in the review period. Together with the disqualification directions, the Determining Authority considered these directions were commensurate with the extremely serious level of inappropriate practice found by the Committee. The practitioner will also receive a reprimand and counselling from the Director.

PSR Committee No.1125

On 17 April 2020, a final determination came into effect regarding Dr Emmanuel Inyang, general practitioner, who practised in Maddington, Western Australia during the review period. The practitioner was directed to be:

reprimanded and counselled,
repay $455,319.28 to the Commonwealth,
disqualified from billing MBS item 36 for a period of three months, and
directed to be disqualified from billing MBS items 703, 705, 715, 721, 732, 2713 and 2717 for a period of 12 months.

The Committee was concerned about the practitioner’s compliance with MBS requirements including where multiple items were billed concurrently, the practitioner’s record-keeping and, in some instances, the practitioner’s clinical input.

In relation to MBS item 36, the Committee found that in almost all cases that the practitioner’s records were inadequate in that they included insufficient clinical detail for another practitioner to understand with much precision what had transpired in the consultation and to explain why a consultation of at least 20 minutes was indicated. Beyond template-generated and irrelevant examination findings (for examinations that were unlikely to have been performed) there was often little clinical content recorded.

The Committee found that health assessment services, billed as MBS items 703 and 705, were often rendered to patients who were not eligible or their eligibility could not be inferred from the record. There was no evidence of regard for the specific requirements for health assessments, which vary depending on the target patient group. Where there was an attempt to complete a health assessment for an eligible patient, there was only very minimal information recorded. Aboriginal and Torres Strait Islander peoples health assessments followed a template but that was often completed in the absence of the patient and lacked clinical detail.

MBS item 721 requires the formulation of a GP management plan in connection with the patient. The Committee found that for a significant number of services a plan was not created. Where it was, it was merely a template with almost no patient-specific content. MBS item 732 requires a review of a GP management plan (or of team care arrangements). The Committee found that the practitioner’s clinical input into those services was limited to, at the most, the collection of clinical measurements. It was difficult to discern meaningful clinical input that could be considered part of the MBS item 732 service.

The Committee found that MBS item 2713 was routinely billed with other attendance items and typically the only content in the record relating to a mental health service was a presenting complaint and a prescription. The item was billed for any mental health service, whether or not there was a 20 minute attendance distinct from concurrently billed items. MBS item 2717 requires a 40 minute attendance for the formulation of a GP mental health treatment plan. In many cases, MBS item 2713 was concurrently billed for the information collection and assessment, which is part of the MBS item 2717 service, and caused the Committee to find that the minimum time for both items had not been met. While there was patient history taken and mental state examinations made, the Committee found that the goals and tasks for the patient were deficient.

The Committee also found that where the practitioner prescribed PBS item 8118G (alprazolam 2mg) and PBS item 8501K (oxycodone 10mg) the associated progress notes were inadequate in that the clinical indication for prescribing was largely unclear and there was never an assessment of the effectiveness of the medication. There was also little indication of any attempt to reduce a patient’s reliance on addictive medication.

The Determining Authority’s repayment direction of $455,319.28 represents the whole of the benefits that were paid for MBS items 36, 703, 705, 715, 721, 732, 2713 and 2717. Together with the disqualification directions, the Determining Authority considered that these directions were commensurate with the serious extent of inappropriate practice found by the Committee. The practitioner will also receive a reprimand and counselling from the Director.

C. Federal Court

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

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

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

E. Referrals to AHPRA (106XA/B)

Five matters were referred to AHPRA in April 2020.