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Upsurge in doctors under billing scrutiny

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A doctor has been ordered to repay Medicare rebates worth almost $1.14 million as part of an upsurge in cases of over-billing being investigated by health authorities.

The Professional Services Review has reported a near doubling of the number of cases referred to it by the Health Department as the conduct of medical practitioners, particularly in the preparation of chronic disease management plans and those working in large practices, comes under increased scrutiny.

In its 2015-16 annual report, the PSR said it had received 80 referrals from the Department, a 29 per cent jump from the previous year and an 82 per cent surge from 2013-14.

Of 49 investigations completed last year, 24 resulted in no further action being taken, while 18 were resolved with a negotiated agreement including the repayment of $1.63 million and the partial disqualification of 12 practitioners.

But in seven instances doctors were reprimanded and ordered to repay Medicare benefits worth between $48,380 and $1.138 million. In one instance, a doctor was disqualified from practising for three months.

In all, doctors were ordered to reimburse Medicare almost $4.6 million.

While the vast majority of the 85,000 practitioners providing Medicare reimbursed services are considered to be doing the right thing, the PSR reported several instances of high billing, including a GP who provided 20,000 services in a single year, as well as almost 600 GP Management Plans, 400 Team Care Arrangements and more than 1000 item 2713 mental health services – each of which has a minimum 20-minute time requirement.

A chronic problem

The agency, which is asked to investigate cases that the Health Department cannot resolve or explain, said the use of Chronic Disease Management (CDM) and Health Assessment items was of particular concern.

“Many practitioners who provide high numbers of these services use computer-generated templates; a plan may have minimal content specific to the patient for whom the plan has been prepared,” it said. “Plans sometimes have very generic health advice of the most minimal nature, and sometimes irrelevant to any condition listed in the patient’s clinical record.”

The PSR said that in other instances some GPs were preparing GP Management Plans every 12 months, and reviewing them every three months, without even consulting the patient.

“In some cases, there was little evidence that patients were aware that they had a GP Management Plan, and the precise regularity of reviews every three months…appeared contrived to maximise income rather than being based on clinical assessment.”

A matter of size

The PSR raised concern about the operation of larger medical practices where GPs are engaged as independent contractors who pay the operator a service fee. It said that under current arrangements individual practitioners were held solely accountable for inappropriate billing and the reimbursement of rebates – practice owners retained their share of Medicare rebates.

Local knowledge

The agency warned that overseas-trained doctors were more susceptible to breaching Medicare rules than their local counterparts, accounting for almost 54 per cent of cases referred to it last financial year.

In one instance, it found an “older English graduate…engaged in particularly egregious use” of CDM items, claiming the MBS items 721 and 723 more than 400 times in 12 months, at $240 a time.

Three other international medical graduates were found to have breached the so-called 80/20 rule, which meant they billed 80 or more GP attendance items on 20 or more days in the year. Typically, this would mean providing between 17,000 and 20,000 services attracting a gross rebate of between $800,000 and $1 million.

In all, five practitioners were investigated by the PSR for breaching the 80/20 rule, while a further 15 were identified to have provided more the 60 attendances on more than 100 days.

In mitigation, many explained that they worked very long hours, they knew their patients well so could serve them quickly, that the practice was under-staffed or that they were unaware of the 80/20 rule.


The PSR flagged that while some doctors were billing CDM items inappropriately, others had come under suspicion over their provision of urgent after-hours care.

It said that although those referred for investigation had generally satisfied the definition of providing after-hours care, their interpretation of what constituted the need for urgent care was dubious.

“Examination of clinical records has shown that some practitioners have billed these items for medical conditions such as an uncomplicated rash, reissuing prescriptions for…regular medication and for routine completion of medication charts in residential aged care facilities,” the PSR said, adding that the difference in fee between urgent and non-urgent after-hours MBS items was substantial enough to have a significant financial impact on Medicare.

The agency warned that the Government’s review of the MBS and Medicare compliance measures was likely to include ways to use the billing system to “better detect and define possible inappropriate practice”.

The Federal Government has begun work on upgrading the Medicare payments system, inviting private sector upgrade proposals, though it has insisted the system and the information it collects will remain completely in public hands.

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