Inappropriate MBS claims: cardiologist repays $750,000 to Medicare

A cardiologist has been reprimanded and agreed to repay $750,000 to Medicare for overclaiming of MBS items for longer consultations and items for investigations such as ankle brachial indices vascular ultrasound.

The un-named cardiologist was investigated by the Professional Services Review (PSR) after audits revealed that their claim rate for some MBS items was excess of 99% of their peers.

The concerns about inappropriate claims related to items 132 (consultations of a duration of at least 45 minutes), 133 (review of a patient with at least 2 morbidities), 162 and 163 (prolonged attendance with a patient in imminent danger of death).

In its latest update the Director of the PSR said they also had concerns about inappropriate claims made by the cardiologist for items relating to measurement of ankle brachial indices for the evaluation of lower extremity arterial disease (11610), exercise study for the evaluation of lower extremity arterial disease (11612), ECG recording (11709, 11712) and respiratory tests for conditions such as pulmonary artery hypertension (11503).

The investigators concluded that MBS item requirements were not always met, including the minimum time requirements  in respect to MBS item 162 and 163 services, the majority of patients were not in imminent danger of death.

It also found that not all of the claimed services were clinically indicated.

“For example, there was not always a focused patient history or relevant examination revealing a clinical justification for performing MBS items 11503, 11610, 11612, 11709 and 11712 tests and the records were inadequate as there was not always evidence of test results or an interpretation of the results,” the PSR report found.

The PSR said the cardiologist acknowledged having engaged in inappropriate practice in connection with providing the items of concern and had agreed to repay $750,000.

The practitioner was also disqualified from providing MBS items 132, 133, 162, 163, 11503, 11610 and 11612 for 24 months, and will be reprimanded by the PSR Director.

Many of the items covered in the audit have been the subject of recent reports from the Medicare Review Taskforce, which recommended changes in MBS items for ECG and vascular disease investigations to discourage inappropriate claiming and low value care.

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