Skin cancer doctor forced to repay almost $500,000 to Medicare

Skin cancers

By Julie Lambert

6 Jul 2021

A doctor has been reprimanded and will repay nearly $500,000 for overclaiming MBS items for skin procedures after an investigation by the Professional Services Review.

The doctor’s skin procedure-related billings across six MBS item exceeded 99% of their peer group during the period reviewed by the Medicare watchdog, according to a statement by PSR Director Dr Julie Quinlivan.

The un-named general practitioner admitted to inappropriate practice in connection with all the MBS items under review and has agreed to repay Medicare $480,0000, according to the PSR.

The practitioner is also banned from performing a core skin procedure for two years.

The ban relates to only one MBS procedural item (30192), for the removal of 10 or more premalignant skin lesions including solar keratoses by ablative techniques.

After its review, the PSR said it had “persisting concerns” relating to the practitioner’s usage of the six skin-related procedural items and two GP attendance items.

It said:

  • The GP’s records were inadequate;
  • MBS requirements were not always met;
  • patient consent was not appropriately obtained and recorded;
  • Not all services were clinically indicated; and
  • Clinical input was inadequate.

The other five MBS skin items of concern were:

  • Item 30071 – skin biopsy for diagnosis;
  • Item 31358  –  surgical excision and repair of a malignant skin lesion, other than those covered by items 31371, 31372, 31373, 31374, 31375 or 31376, other than by shave excision, if: a)  the lesion is excised from nose, eyelid, eyebrow, lip, ear, digit or genitalia, or from a contiguous area; and (b)  the necessary excision diameter is 6 mm or more; and (c) the excised specimen is sent for histological examination; and (d) malignancy is confirmed from the excised specimen or previous biopsy;
  • Item 31363  –  excision of malignant skin lesions on the face, neck, scalp, nipple-areola complex, upper and lower distal limbs;
  • Item 45201 –   muscle, myocutaneous or skin flap, where clinically indicated to repair one surgical excision made in the removal of a malignant or non-malignant skin lesion (only in association with items 31000, 31001, 31002, 30003, 31004, 31005, 31358, 31359, 31360, 31363, 31364, 31369, 31370, 31371, 31373 or 31376); may be claimed only once per defect; and
  • Item 45451  –   full-thickness skin graft

Of the two GP attendance items, MBS item 23 relates to professional attendance by a GP for less than 20 minutes. Item 5020 covers a GP attendance of less than 20 minutes that includes taking a patient history, performing a clinical examination, arranging any necessary investigation, implementing a management plan, or providing appropriate preventive care in relation to one or more health-related issues, with appropriate documentation.

The PSR has previously flagged that it would be clamping down on inappropriate Medicare billing relating to  skin medicine items by non-dermatologist practitioners .

In its annual report for 2018-19 the PSR said it had received a number of referrals relating to practitioners classified as ‘Other Medical Practitioner’ or ‘Specialist General Practitioner’ classification rather than ‘Specialist Dermatologist’ category.

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