PSR Director's Update for June 2019

A. Director’s Section 92 agreements effective in June 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 surgeon.

The practitioner billed more than 17,000 services in the year under review, including more than 90 services on 59 days. The Director reviewed this practitioner’s rendering of Medicare Benefit Schedule (MBS) items 104, 105, 18264, 32000, 32006, 32025, 32072, 32093, 32111, 32129, 32131, 32135, 32139, 32145, 32165, 35595 and 45200 and had no concerns in relation to MBS item 104. The Director had persisting concerns that:

• records of consultations and procedures were either non-existent or inadequate;
• MBS item 105 was often billed for consultations that were post-operative in nature or for the rendering of a therapeutic item;
• consent to procedures for all therapeutic procedures was either not adequately obtained or not adequately recorded;
• MBS requirements were not met for many services (in that multiple items were often billed for what peers might consider a single service or the service was not otherwise performed in accordance with the descriptor (or at all));
• not all services were clinically indicated, with the practitioner often appearing to proceed straight to a surgical option ahead of more conservative forms of treatment where only mild symptoms were identified; and
• clinical input was inadequate or inadequately recorded.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $500,000, to be disqualified from providing MBS items 32131 and 32111 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed more than 15,000 services in the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 36, 721, 723, 5020, 5040, 55808, 57521, 66716, 66833 and 66839 and had persisting concerns that:

• level B and C consultations – that the practitioner’s records were inadequate, clinical input was inadequate and the MBS requirements were not met, including minimum time requirements (where applicable). For example some records were opened for less than five minutes and/or the history was omitted and/or relevant systems were not examined and/or the patient attended for the results of simple tests (such as a normal urine test) and/or iron infusions were performed when patients had normal iron studies ;
• chronic disease management services – the MBS requirements were not always met, clinical input was inadequate and records were inadequate as patients did not have a suitable chronic disease and/or there were no individualised goals and/or there was there was no collaboration with at least two other health care providers documented in the records; and
• diagnostic imaging services – the records were inadequate and did not support the ordering of the scans, MBS requirements were not met and clinical input was inadequate as imaging was ordered without a relevant history or examination recorded.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items. The practitioner agreed to repay $428,000, to be disqualified from providing MBS items 721, 723 for 24 months, to be disqualified from providing MBS items 36, 55808, 66716, 66833 for 12 months, and will be reprimanded by the Director.

An agreement with a rehabilitation medicine specialist.

The practitioner was a national top biller for three item numbers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 110, 116, 132, 133, 830, 834 and 880 and had persisting concerns that:

• the MBS requirements, including the minimum time requirements, were not always met;
• the records were inadequate and, for MBS item 132 and 133 services, records were often not present;
• the practitioner provided insufficient clinical input into some services. For example, in-patient reviews sometimes just stated that a patient was doing well and no other information.
• In regard to case conferences concerns included a failure to secure patient consent to hold a case conference, documentation to support billing the case conference being absent or the only documentation being a stamp saying a case conference was held without other detail;
• the practitioner rendered some services that were not clinically indicated including by co‑billing attendance items and case conference items without there always being a separate medical issue recorded to justify the billing of a separate attendance item.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $170,000, to be disqualified from providing MBS item 133 for 12 months, and will be reprimanded by the Director.

An agreement with a respiratory and sleep medicine specialist.

The practitioner billed MBS item 12250 on more than 5000 occasions in the year under review. The Director reviewed this practitioner’s rendering of MBS item 12250 and had persisting concerns that the practitioner:

• billed for services performed by other practitioners;
• did not always provide adequate clinical input into services;
• did not always comply with the requirements of MBS item 12250; and
• did not always document a clinical indication for the service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing this item of concern. The practitioner agreed to repay $900,000, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed in excess of 84% of their peers despite having a patient load that was on the 38th centile compared with their peers during the year under review. The practitioner billed chronic disease management services in excess of 99% of their peers during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 721, 723, 732, 5020, 66650, 66653, 66656, 66716 and 66833, and Pharmaceutical Benefits Scheme (PBS) item 8254K and had no concerns in relation to MBS item 5020. The Director had persisting concerns that:

• the clinical records were inadequate and did not support that MBS requirements were met;
• the clinical input was not always adequate. For example many GP Management Plan and Team Care Arrangement documents were identical blank templates which did not detail suitable chronic diseases and the records did not always reflect collaboration with at least two other health care providers;
• not all services were clinically indicated;
• large numbers of tests were ordered for the purpose of screening patients with no relevant history or examination documented in the record; and
• PBS item descriptor 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 $350,000, to be disqualified from providing MBS items 721, 723, 732, 66650 and 66653 for 12 months, to be disqualified from providing MBS item 66656 for 6 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed over 16,000 services during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 36, 53, 5020, 16500, 30062 and 31206 and had no concerns in relation to MBS item 30062. The Director had persisting concerns that:

• the MBS requirements for services were not always met;
• the medical records kept by the practitioner were inadequate as they were brief and missing key information;
• the records for antenatal attendances failed to document an obstetric examination or fetal heart beat;
• the practitioner appeared to paste identical text across multiple entries in the medical record for multiple patients and in some cases the text was not relevant to the presentation, yet relevant patient history and/or examination was omitted;  and
• the practitioner did not always provide adequate clinical input into the service they billed.

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 36, 16500 and 31206 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner.

The practitioner billed in excess of 51% of their peers despite having a patient load that was on the 13th centile when compared with their peers during the year under review. The practitioner billed long consultation items in excess of 99% of their peers during the year under review. The Director reviewed this practitioner’s provision of MBS items 57, 5040, 5060, 56307, 56619, 66707, 66719, 66734 and 66839, and PBS items 10104T, 2622B, 3119E, 3162K, 5438F and 8254K and had persisting concerns that:

• the practitioner billed Medicare for treating family members, including prescribing them opioids, and also initiated diagnostic tests for himself;
• the records were inadequate;
• MBS requirements were not always met, including minimum time requirements;
• services were not always clinically indicated, including where diagnostic imaging and pathology services were initiated, and consultations billed in respect of a cosmetic procedure; and
• patients were not always present when prescriptions were issued, prescribing was not always clinically indicated 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 $400,000, to be disqualified from providing MBS items 57, 5040, 5060, 56619, 66707 and 66734 for 12 months, and will be reprimanded by the Director.

An agreement with a medical practitioner.

The practitioner billed consultations in excess of 99% of their peers despite having a patient load that was on the 58th centile when compared with their peers during the year under review. The Director reviewed this practitioner’s rendering of MBS items 36, 44, 715, 721, 723, 732 and 2143 and had persisting concerns that the practitioner:

• did not always provide services that met the MBS requirements, especially minimum time requirements. For example, MBS item 44 was billed for straightforward presentations such as viral gastroenteritis, which is unlikely to require more than 40 minutes of clinical input;
• did not always keep adequate clinical records;
• did not always provide adequate clinical input into the services they provided; and
• co-billed MBS items, without there being appropriate justification for each service.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $200,000, to be disqualified from providing MBS item 732 for 12 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed in excess of 77% of their peers despite a patient load that was on the 18th centile when compared with their peers during the year under review. The Director reviewed this practitioner’s provision of MBS items 36, 44, 721, 723, 732, 2521, 2713, 2717, 5060, 66653 and 66833, and PBS items 8254K and had no concerns in relation to MBS item 2521 and PBS item 8254K. The Director had persisting concerns that:

• MBS requirements were not always met, including time requirements;
• records were inadequate;
• services were not clinically indicated;
• billing of consultation items in association with mental health items was not supported by the records. For example most MBS items 36, 44 and 5060 services were also co-billed with MBS item 2713 without documentation supporting each separate service;
• on some days timed consultations alone exceeded 19 hours before untimed consultations or services were included, raising a concern as to whether minimum time requirements were always met; and
• chronic disease management services were regularly billed where there was no evidence the practitioner attended the patient on the dates of service or had provided input into the plans created. 

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $460,000, to be disqualified from providing MBS items 44, 721, 732, 2717 and 66653 for 12 months, to be disqualified from providing MBS items 2713 for 6 months, and will be reprimanded by the Director.

An agreement with a general practitioner.

The practitioner billed more than 15,000 services during the year under review. The Director reviewed this practitioner’s provision of MBS items 23, 36, 721 and 723, and PBS items 3119E and 8254K and had no concerns in relation to MBS item 23 and PBS items 3119E and 8254K. The Director had persisting concerns that:

• MBS requirements were not met, including the minimum time requirement for MBS item 36. For example, MBS item 36 was billed for presentations such as a viral upper respiratory tract infection or for repeat prescription or for a simple check of the blood pressure;
• not all services were clinically indicated; and
• records were inadequate.

The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $130,000, to be disqualified from providing MBS items 36, 721 and 723 for 12 months, and will be reprimanded by the Director.

B. PSR Committee final determinations

Two final determinations became effective in June 2019.

PSR Committee No. 1055:

On 25 June 2019, a final determination came into effect concerning Dr Gamal Mansour, formerly of SIA Medical Centre, 1138 Mount Alexander Road, Essendon, Victoria. Dr Mansour was directed to be reprimand and counselled by the Director. He was disqualified from providing MBS items 36, 721, 723 and 732 for a period of 24 months and directed to repay $591,730.45 to the Commonwealth. These directions followed from a final report of a PSR Committee, which concluded that Dr Mansour engaged in inappropriate practice for services that he rendered as MBS items 23, 36, 707, 721, 723 and 732.

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

• the MBS requirements for the item number were not met, in that Dr Mansour did not keep appropriate documentation of the service; and
• Dr Mansour's clinical input into the service was inadequate.

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

• the MBS requirements for the item number were not met, in that Dr Mansour did not keep appropriate documentation of the service and/or the service did not last at least 20 minutes; and
• Dr Mansour’s clinical input into the service was inadequate.

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

• Dr Mansour’s clinical input into the service was inadequate; and
• the MBS requirements for the item number were not met, on the basis that Dr Mansour did not keep appropriate documentation of the service and/or the service did not last at least 60 minutes.

In relation to MBS item 721 services, the Committee found:

• the MBS requirements for the item number were not met because either Dr Mansour did not prepare a GP Management Plan for the patient, or the plan that was prepared was not a comprehensive written healthcare plan, and/or Dr Mansour was not the patient’s regular GP as required; and
• Dr Mansour’s clinical input into the service was inadequate. 

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

• the MBS requirement for the item number were not met in that:
  • Team Care Arrangements were not prepared for the patient and/or if they were, the document was inadequate;
  • there was no record of Dr Mansour collaborating appropriately with at least two other providers;
  • the evidence did not indicate that the patient’s condition was present for at least six months as required; and
  • the patient’s goals were not individualised to the patient’s conditions and were brief and not measurable;
• Dr Mansour’s clinical input into the service was inadequate. 

In relation to MBS item 732 services, the Committee found:

• The MBS requirements for the item number were not met in that:
  • a review of a GP Management Plan or Team Care Arrangement was not always performed;
  • the review documents did not contain any measurable goals, specific actions to be taken by the patient or individualised goals specific to the patient’s health needs; and
  • there was not always evidence that at least two other healthcare providers were consulted to review the matters set out in the plan;
• Dr Mansour’s clinical input into the service was inadequate. 

PSR Committee No. 1123:

On 25 June 2019, a final determination came into effect concerning a general practitioner. The practitioner was directed to be reprimand and counselled by the Director. They were directed to repay $162,802.15 to the Commonwealth. 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 and prescriptions provided as PBS items 1609Q, 1655D, 3133X, 8387K, 8492Y, 8493B, 8493C and 8254K.

The Committee’s findings for the MBS item 23 services in relation to which the practitioner was found to have engaged in inappropriate practice were for the following reasons:

• the practitioner failed to keep adequate records and in particular, the records often failed to include sufficient particulars of the history and presenting complaint; and
• there were also a number of clinical concerns, including that the practitioner did not appear to have performed clinically indicated examinations.

The Committee found that the practitioner engaged in inappropriate practice in relation to their prescribing of the relevant PBS items as follows:

PBS item 1609Q (methadone 10mg tablets)

• the Committee found that the practitioner’s record was inadequate, in that in every case it omitted a meaningful assessment of the patient’s progress; and
• in some cases the Committee had concerns that methadone was being prescribed to treat opioid addiction and not any significant pain disorder.

PBS items 1655D (morphine modified release tablets 60mg), 8492Y (morphine modified release capsules 60mg), 8493B (morphine modified release capsule 90mg) and 8494C (morphine modified release capsule 120mg)

• the Committee found that the record made was inadequate;
• in many cases, the Committee also found that there was no proper attempt to reduce a patient’s dosage during the review period; and
• in some cases, whilst the Committee did not have all documentation relating to the commencement of the medication, the Committee was seriously concerned that patients were prescribed opioid medication initially, and had their dosages increased over time, after seemingly minor injuries.

PBS item 3133X (oxazepam 30mg tablets)

• the Committee found that the practitioner’s medical records made in connection with prescriptions for oxazepam were inadequate; and
• the Committee also found that the practitioner’s management was deficient in relation to  patients whose records were reviewed.

PBS item 8387K (oxycodone modified release tablet 40mg)

• the Committee found that the clinical record made on each occasion was similar to one another, did not contain a proper assessment of the patient, and it was difficult to know what happened from one consultation to the next; and
• the Committee was also concerned about the clinical management of some patients.

PBS item 8254K (amoxicillin 875mg + clavulanic acid 125mg tablet)

• the Committee found that on each occasion Augmentin was prescribed, the practitioner’s medical record was inadequate. The record often did not disclose a clinical indication for the prescription and where it did, for example, by mentioning a respiratory condition, the history and examination findings were inadequate to explain why Augmentin was indicated; and
• in addition, the Committee found that the practitioner’s records did not disclose that resistance to amoxicillin was suspected or proven.

C. Federal Court

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

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

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

E. Referrals to AHPRA (106XA/B)

Three matters were referred to AHPRA in June 2019