PSR Director's Update for September 2019

Published date

8 October 2019

A. Director’s Section 92 agreements effective in September 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 in excess of 99 percent of their peers, despite have a patient load on the 70th centile during the year under review with a service to patient ratio exceeding the 98th centile despite also having a percentage of long consultations above the 99th centile. The Director reviewed this practitioner’s rendering of MBS items 23, 36, 30192, 31363, 56223, 56507, 56807, 66596, 66650, 66653 and 66656 and PBS items 2622B, 3119E, 3162K, 8254K, 8601Q and 8785J, and had no concerns in relation to MBS items 30192 and 66656 and PBS item 8601Q. The Director had persisting concerns that:

The records were very brief and often did not record a patient history, examination, diagnosis or management plan. Many contained only one to three words as the entire entry;
MBS requirements were not always met, including time requirements (where relevant) or histopathology requirements where excised lesions were required to be malignant but pathology was benign or else the lesion was considerably smaller than the required size or excised from a different part of the body to that in the descriptor;
records were inadequate;
there was excessive ordering of some pathology and radiology items without documented clinical indication or where patients failed to meet the eligibility for the tests;
services were not all clinically indicated, including prescribing of PBS medications; and
PBS requirements were not always met.

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 providing MBS items 36 for 6 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed MBS items 36 and 44 in excess of 99 percent of their peers during the year under review despite having a patient load on the 83rd centile. Long consultations were billed well above the 99th centile and constituted 68% of all billed services. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 715 and 732. The Director had persisting concerns that the practitioner did not always:

provide services that met the MBS requirements, including the minimum time requirements (where relevant);
keep adequate medical records;
provide adequate clinical input into the services billed.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern and demonstrated insight and made a large voluntary repayment during the review process. The practitioner agreed to repay a further $10,000, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed in excess of 77 percent of their peers, despite have a patient load on the 14th centile during the year under review. Overall 67% of consultations were billed as long or extended consultations and the practitioner billed level D services 58 times more often than peer general practitioners and was the 11th highest biller in all Australia for this item. Assuming minimum time requirements this constituted billing of more than 13 hours on some days before any untimed consultations were even considered. The Director reviewed this practitioner’s rendering of MBS items 36, 43, 44, 51 and 707, and PBS item 1891M. The Director had persisting concerns that the practitioner did not always:

meet the MBS requirements for services rendered, including the minimum time requirements;
provide sufficient clinical input into the services rendered;
keep adequate clinical records; and
comply with the PBS restrictions when prescribing amoxicillin with clavulanic acid.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $290,000, to be disqualified from providing MBS items 44 and 707 for 12 months, and will be reprimanded by the Director.

An agreement with a respiratory and sleep medicine physician.

The practitioner billed MBS item 12250 more than 2000 times during the year under review and was a national top biller of this item. The Director reviewed the practitioner’s rendering of MBS item 12250. The Director had persisting concerns that:

MBS item requirements were not always complied with;
services were not always clinically indicated; and
the practitioner did not always provide adequate clinical input.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing this item of concern. The practitioner agreed to repay $200,000, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed over 14,000 services during the year under review and regularly billed more than 70 professional services in a day. The Director reviewed this practitioner’s rendering of MBS items 23, 721, 723 and 732, and PBS items 3119E and 8254K. The Director had persisting concerns that the practitioner:

did not keep adequate medical records of the services provided;
did not always provide adequate clinical input in that records of services were very brief and did not include patient history, examination, diagnosis and management plans and often involved ordering large volumes of pathology and radiology without documented clinical indication;
did not always meet the MBS requirements for the services rendered;
services were not always clinically indicated, for example a patient would present with another simple problem and a care plan and team care items would be billed when the patient was not eligible for the service or there was no assessment of their chronic disease;
in some cases there was no evidence the patients were present when some services were billed;
prescribed antibiotics without appropriate clinical indication and prescribed PBS item 8254K outside the PBS requirements.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $350,000, to be disqualified from providing MBS items 721, 723, 732 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

Two final determinations became effective in September 2019.

PSR Committee No. 1052:

On 6 September 2019, a final determination came into effect concerning Dr Mainul Hossain, a medical practitioner who practised in Morisset, New South Wales during the year under review. Dr Hossain was directed to be reprimanded and counselled by the Director, directed to repay $580,108.94 to the Commonwealth and was directed to be disqualified from MBS items 44, 57, 721, 723, 732, 2713 and 2715 for a period of 12 months. These directions followed from a final report of a PSR Committee, which concluded that Dr Hossain engaged in inappropriate practice in connection with services rendered as MBS items 53, 54, 57, 721, 723, 732, 2713 and 2715.

The Committee’s findings for the MBS item 53, 54 and 57 services in relation to which Dr Hossain was found to have engaged in inappropriate practice were for one or more of the following reasons:

Dr Hossain allowed another practitioner, who was not qualified to bill Medicare, to see patients and bill Medicare under his Medicare provider number for services they rendered.
Dr Hossain did not meet the Medicare requirements for billing item 53, 54 and 57 services in relation to duration of clinical input required to bill those items.
Dr Hossain failed to keep adequate records and, in particular, the records often did not demonstrate sufficient clinical input to justify the items billed.
Dr Hossain had sometimes co-billed an item 57 service with an item 2713 service and on those occasions did not comply with Medicare requirements.
Concerns were raised with respect to Dr Hossain’s clinical acumen, in particular with regard to the frequency of prescribing drugs of addiction in the absence of a clear management plan, or appropriate compliance checking.

The Committee’s findings for the MBS item 721, 723 and 732 services in relation to which Dr Hossain was found to have engaged in inappropriate practice were for one or more of the following reasons:

Dr Hossain allowed another practitioner to bill Medicare under his Medicare provider number for services they rendered.
Dr Hossain’s records were inadequate. He had relied upon template documents, which were not individualised to the patient, and had often not offered any clinical input to the creation of such records (which was undertaken by others), other than signing them. In addition, many of the records made available and examined by the Committee had not been signed.
In many cases it was not apparent that a patient had an eligible chronic disease.
Dr Hossain had not complied with MBS item requirements. For example, in most Team Care Arrangements reviewed he failed to consult with two other healthcare providers. The Committee viewed this as a critical component of the MBS item descriptor.

The Committee’s findings for the MBS item 2713 and 2715 services in relation to which Dr Hossain was found to have engaged in inappropriate practice were for one or more of the following reasons:

Dr Hossain failed to comply with the MBS item requirements, including the minimum time requirements.
Dr Hossain had not provided sufficient clinical input to justify the services billed generally, but particularly on occasions in which Dr Hossain had co-billed a mental health item and a standard consultation.
Dr Hossain’s records were not adequate, and lacked appropriate clinical detail such that the Committee was concerned that another practitioner would find it difficult to effectively take over patient care, based upon the content of Dr Hossain’s notes.

PSR Committee No. 936:

On 18 September 2019, a final determination came into effect concerning a medical practitioner. The practitioner was directed to be reprimanded and counselled by the Director, directed to repay $526,477.75 to the Commonwealth and was directed to be disqualified from MBS item 36 for a period of six months, MBS items 585, 588, 591 and 594 for a period of 12 months and MBS items 160 and 707 for a period of 24 months. These 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, 160, 597 and 707.

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

In relation to the MBS item 23 services, the Committee found that the medical practitioner:

Failed to meet the requirements of the MBS item descriptor,
Failed to provide adequate clinical input in relation to the presenting complaint, and/or
Failed to keep an adequate and contemporaneous record.

In relation to the MBS item 36 services, the Committee found that the medical practitioner:

Failed to meet the requirements of the MBS item descriptor,
Failed to provide adequate clinical input in relation to the presenting complaint,
Billed separately for procedures performed that were included as part of the MBS item 36 service that was billed, and/or
Failed to keep an adequate and contemporaneous record.

In relation to MBS item 160 services, the Committee found that the medical practitioner:

Failed to meet the requirements of the MBS item descriptor,
Failed to provide adequate clinical input in relation to the presenting complaint, and/or
Failed to keep an adequate and contemporaneous record.

In relation to MBS item 597 services, the Committee found that the medical practitioner:

Failed to meet the requirements of the MBS item descriptor as services provided were not urgent,
Failed to provide adequate clinical input in relation to the presenting complaint and failed to take an adequate history, perform the relevant examination, make an appropriate diagnosis and instigate the correct management plan, and/or
Failed to keep an adequate and contemporaneous record of billed services.

In relation to MBS item 707 services, the Committee found that the medical practitioner:

Failed to meet the requirements of the MBS item descriptor, and/or
Failed to keep an adequate and contemporaneous record.

C. Federal Court

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

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

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

E. Referrals to AHPRA (106XA/B)

One matter was referred to AHPRA in September 2019.