Medicare’s investigative arm has banned a dermatologist from billing MBS items for a year – but the reasons why must remain secret.
A dermatologist has been sanctioned by a Professional Services Review (PSR) committee – including being denied access to MBS items – after the committee determined the practitioner had inappropriately billed several different MBS items.
In addition to being disqualified from billing MBS services, the dermatologist will receive a formal reprimand and counselling, and be required to repay $237,450 to the Commonwealth.
The sanctions, which were outlined in the PSR director’s September 2022 update, come as concerns grow about the accountability and transparency of Medicare’s investigative arm. Following the ABC/Nine Newspapers’ joint investigation of alleged Medicare rorting, Health Minister Mark Butler has ordered an independent review of Medicare’s regulatory mechanisms, including the PSR.
To protect their privacy, the dermatologist was not named in the director’s update. However, critics of the PSR’s operations say one of their greatest concerns is that under the Health Insurance Act, participants in a PSR investigation are also forbidden from disclosing any details, including evidence tendered to a PSR committee.
This effectively allows the committee to operate in secret.
In the cases of the dermatologist, the committee raised several concerns about each MBS item. For example, it argued the requirements of MBS items 104 and 105 had not been met based on one or more of the following concerns:
- there was no valid referral for the service
- for item 104, the service was not an initial attendance in a single course of treatment and no initial consultation was performed
- the only medical record for the date of service was for a co-billed procedural item and where there was no evidence of a consultation separate to the procedure having been performed
- services were not clinically relevant and were performed for purely cosmetic reasons
- clinical input was inadequate
- the medical record was inadequate
- there was no letter back to the referring practitioner where such a letter was indicated and/or specifically requested by the referring practitioner
The sanctions are based on the dermatologist’s practice between 1 July 2015 and 30 June 2016, showing that investigations can often stretch out for years, even once the PSR director has established a committee to conduct the inquiry.
The committee also determined the practitioner had billed MBS item 14109 inappropriately based on one or more of the following:
- the MBS item requirements were not met in that the services related to treatments not permitted (or expressly excluded) by the descriptor, and the minimum size requirement for the treatment area was not satisfied
- the medical record was inadequate.
And for MBS item 18234, the committee determined the dermatologist had practised inappropriately based on one or more of the following:
- MBS item requirements were not met as the service did not involve an injection of anaesthetic to the primary division of the trigeminal nerve
- the medical record was inadequate
- there was no letter back to the referring practitioner where such a letter was indicated and/or specifically requested
Other more specific concerns were that:
- the item was billed for sub-cision and/or TCA-CROSS therapies performed over multiple visits as part of a course of treatment, with each instance involving partial scar revision only, rather than for a complete scar revision in a single service
- the therapy performed at each service did not match the complexity of a surgical excision with closure expected for a complete scar revision service, and noting other MBS items available for simple scar revision procedures
Other health professionals who spoke to Dermatology Republic’s sister publication, The Medical Republic, said while they were prevented under law from disclosing details, they believed they had provided their own PSR investigating committees with detailed, documentary evidence that refuted their concerns.
However, under current law, a committee’s reasons for rejecting such evidence must remain secret.
