PSR Director's Update for November 2019

Published date

3 December 2019

A. Director’s Section 92 agreements effective in November 2019

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 general practitioner.

The practitioner billed Medicare Benefits Schedule (MBS) items 707, 739, 2700, 11506, 11600, 11610, 11700, 55238, 57341, 63560 and 61307 in excess of 99 percent of their peers during the review period. The Director reviewed this practitioner’s provision of MBS items 36, 44, 160, 707, 721, 723, 732, 739, 2700, 11610, 11700, 55238, 57341, 61307 and 63560, and Pharmaceutical Benefits Scheme (PBS) items 3119E and 8254K, and had no concerns in relation to MBS item 57341. The Director had persisting concerns that the:

medical records were inadequate;
practitioner did not provide sufficient clinical input into some of the services;
MBS requirements were not always met;
practitioner provided and initiated diagnostic procedures without documented clinical indication;
practitioner prescribed antibiotics where there was no documented bacterial infection; and
practitioner prescribed amoxicillin with clavulanic acid outside the PBS restriction.

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 providing MBS items 160, 721, 723, 732, 2700 and 11610 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed a large volume of daily services during the review period, including more than 60 professional attendances on more than 30 occasions. The Director reviewed this practitioner’s rendering of MBS items 23, 35, 36, 43, 707, 721 and 732, and PBS item 3119E. The Director had persisting concerns in relation to MBS items 707, 721 and 732 that:

the practitioner did not always personally attend the patient for a professional attendance item;
MBS requirements were not always met;
records were inadequate;
clinical input was inadequate, or inadequately recorded; and
services were not always clinically indicated.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $105,000, to be disqualified from providing MBS items 721 and 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed more than 15,000 services during the review period. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 5020, 56223 and 56507, and PBS items 2622B, 3162K, 8611F and 8785J, and had no concerns in relation to PBS item 2622B. The Director had persisting concerns in relation to the remaining items that:

the practitioner did not keep adequate medical records;
MBS requirements were not always met;
the practitioner did not always provide adequate clinical input;
the practitioner initiated diagnostic imaging services without appropriate clinical indication;
the practitioner prescribed drugs of dependence in circumstances that were not clinically appropriate; and
PBS restrictions were not always complied with.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $300,000 and will be reprimanded by the Director.

B. PSR Committee final determinations

Two final determinations became effective in November 2019.

PSR Committee No. 1016

On 6 November 2019, a final determination came into effect concerning Dr Deborah Sambo, a general practitioner who practised in Deception Bay, Queensland during the year under review. Dr Sambo was directed to be reprimanded and counselled by the Director, directed to repay $409,042.64 to the Commonwealth and was directed to be disqualified from MBS items 44 and 723 for a period of six months and MBS item 2717 for a period of 12 months. The directions followed from a final report of a PSR Committee, which concluded that Dr Sambo engaged in inappropriate practice in connection with services rendered as MBS items 36, 44, 723, 2713 and 2717.

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

In relation to the MBS item 36 and 44 services, the Committee found that:

Dr Sambo's progress notes were not always contemporaneous;
Dr Sambo's progress notes were not always adequate;
Dr Sambo's progress notes did not always justify the provision of an MBS item 36 or 44 consultation; and
less commonly, Dr Sambo did not provide appropriate clinical input into services rendered.

In relation to the MBS item 723 services, the Committee found that Dr Sambo:

failed to always create adequate documentation;
failed to always appropriately engage at least two collaborating providers;
in some cases, created team care arrangements that were template based, and not individualised for patients; and
did not always meet the regulatory requirements for team care arrangements.

In relation to MBS item 2713 services, the Committee found that:

in some instances, Dr Sambo's clinical notes did not record clinical content relevant to a mental health consultation.
Dr Sambo's notes were often of low quality. There was rarely sufficient documentation of findings of a mental state examination, history was not adequately documented and it was usually not possible to comprehend or understand the patient's mental health or the treatment provided on the date of the service;
the clinical content recorded for mental health consultations was often very brief, and did not indicate that a consultation lasting at least 20 minutes had been provided;
there were some clinical concerns with respect to Dr Sambo's management of a patient with a history of chronic suicidal thoughts and suicide attempts.

In relation to MBS item 2717 services, the Committee found that Dr Sambo:

did not always comply with the MBS item descriptor;
had, on occasion, failed to prepare necessary documentation;
created documents that were template based, were not customised for each individual patient and did not contain sufficient clinical input for another practitioner to readily understand the status of the patient's mental health; and
often recorded minimal clinical input and the details which were recorded failed to support the rendering of a 40 minute consultation.

PSR Committee No. 1144

On 4 November 2019, a final determination came into effect concerning Dr Hong Hui Chew, a general practitioner who practised in Hawthorn East, Victoria during the year under review. Dr Chew was directed to be reprimanded and counselled by the Director, directed to repay $312,942.03 to the Commonwealth and was directed to be disqualified from MBS items 44, 14100 and 30207 for a period of 12 months. The directions followed from a final report of a PSR Committee, which concluded that Dr Chew engaged in inappropriate practice in connection with services rendered as MBS items 36, 44, 14100, 30195 and 30207.

The Committee’s findings for the MBS item 36 services in relation to which Dr Chew was found to have engaged in inappropriate practice were for one or more of the following reasons:

a substantial proportion of the services examined were provided for cosmetic purposes, rather than being clinically necessary;
Dr Chew appeared to bill item 36 as a standard consultation during the review period;
in some instances, Dr Chew failed to record any notes to document a consultation;
where Dr Chew did record consultations, they often did not reflect the level of clinical input Dr Chew advised the Committee that she provided during the consultation, and her notes appeared to rely on standard macro entries;
in most cases the medical record did not reflect sufficient clinical input to warrant an MBS item 36 consultation of at least 20 minutes in duration;
Dr Chew frequently billed item 36 consultation in combination with other MBS items, in circumstances where her clinical notes did not justify the billing of a separate consultation in addition to a treatment provided; and
in some instances, Dr Chew appeared to have billed Medicare for a post-operative care contrary to Medicare requirements.

The Committee’s findings for the MBS item 44 services in relation to which Dr Chew was found to have engaged in inappropriate practice were for one or more of the following reasons:

many of the services examined were provided for cosmetic reasons so were not clinically necessary and therefore not eligible to be rebated under the Medicare scheme;
Dr Chew had not complied with the MBS item requirements;
frequently, Dr Chew had not recorded important details such as patient history, detailed explanation in management plans and the Committee found that, even if Dr Chew had performed one of the required elements in order to appropriately bill an item 44 consultation, her notes did not adequately document this; and
it was highly likely that Dr Chew had a predetermined course of billing, for financial, rather than clinical reasons, and proceeded to bill according to that course, regardless of the patient’s actual presentation.

The Committee’s findings for the MBS item 30195 services in relation to which Dr Chew was found to have engaged in inappropriate practice were for one or more of the following reasons:

there were widespread concerns that most of Dr Chew’s MBS 30195 services were rendered for cosmetic reasons, rather than being clinically necessary. Patient records usually disclosed minor skin conditions for which medical intervention was not necessary;
across the reviewed services, Dr Chew only exceptionally rarely ordered histopathology in relation to the removal of skin lesions. Absent evidence to the contrary in the medical records, the Committee considered that removal of lesions not expected to be malignant would usually be considered a cosmetic procedure;
there were widespread concerns that Dr Chew had not met the MBS item descriptor, in that MBS item 30195 item was rendered for treatment of lesions which were not benign neoplasms, as required in order to render an item 30195 service. The Committee found that Dr Chew’s understanding of MBS item 30195 was not consistent with that of her peers, notwithstanding the materials Dr Chew relied upon in support of her billing item 30195 for a range of types of skin lesions treated in her practice; and
Dr Chew’s treatment of syringomas was for cosmetic purposes, in the absence of evidence of Dr Chew obtaining histopathology to confirm the diagnosis, or evidence of significant psychosocial impact on the patient, or other evidence to substantiate the medical necessity of treating the condition;
Dr Chew’s billing of item 30195 for treatment by fractionated laser did not comply with the MBS item requirements (and Dr Chew’s notes failed to substantiate her claim that she also used an ablative laser procedure);
Dr Chew’s records were not sufficient with respect to recording use of anaesthetic and in general, were confusing, and not sufficient to enable another practitioner to take over patient care; and
Dr Chew had co-billed almost all item 30195 services with an MBS item 36 service in circumstances where the record did not reflect that an attendance separate to the procedure was clinically indicated, or that an attendance in excess of 20 minutes duration occurred or was clinically warranted.

The Committee’s findings for the MBS item 30207 services in relation to which Dr Chew was found to have engaged in inappropriate practice were for one or more of the following reasons:

many of the services rendered by Dr Chew were for cosmetic, rather than medical reasons;
Dr Chew’s notes were generally poor, and would not be acceptable to the body of general practitioners. In a number of services reviewed, there was no record of an injection being performed, making it impossible to determine if a service to which MBS item 30207 related was provided. As such, even if a service was provided, Dr Chew’s notes were not sufficient to document this; and
all of the item 30207 services were co-billed with an MBS item 36 service, where there was no evidence that a separate consultation was medically indicated, or a consultation of at least 20 minutes in duration actually occurred. If any such services did occur, the records were not sufficient to establish this.

The Committee’s findings for the MBS item 14100 services in relation to which Dr Chew was found to have engaged in inappropriate practice were due to the inadequacy of the records and in some cases, because the MBS requirements did not appear to have been met.

C. Federal Court

No decisions from the Federal Court were handed down in November 2019.

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

No matters were referred to the major non-compliance (fraud) division in November 2019.

E. Referrals to AHPRA (106XA/B)

No matters were referred to AHPRA in November 2019.