Sleep medicine specialist forced to repay $470,000 in MBS claims


By Michael Woodhead

1 Jul 2019

A respiratory and sleep medicine specialist has been reprimanded by the Medicare claims watchdog and ordered to repay almost half a million dollars for inappropriate claiming of sleep studies MBS items.

The un-named practitioner was reviewed by Medicare’s  Professional Services Review  (PSR) in relation to MBS items 11503 for complex lung function tests and item 12250 for unattended home-based sleep studies.

According to the latest PSR bulletin, the PSR Director “had persisting concerns that: for MBS item 11503, the test had not been ordered by the referring GP, the practitioner did not supervise the test or provide quality assurance, and there was no independent report of the test.”

For MBS item 12250, the PSR Director was concerned that there was inadequate consideration of clinical indication for the study, the practitioner’s supervision was inadequate, and the reports were inadequate.

“The practitioner acknowledged they engaged in inappropriate practice in connection with providing these items of concern. The practitioner agreed to repay $470,000, to be disqualified from providing MBS items 11503 for 12 months, and will be reprimanded by the Director,” the PSR statement said.

The reprimand follows major revisions to respiratory function test and sleep study items implemented in November 2018 by Medicare in response to major growth in billing for sleep item numbers.

In its most recent newsletter the Australian Sleep Association said many sleep physicians had asked for clarification about the administration of the questionnaires for items 12203 and 12250.

“[The Department of Health] has communicated to us that it is acceptable for the respiratory/sleep medicine practitioner (or their practice staff) to administer the screening questionnaires when an incomplete referral is received from the referring doctor (i.e. when screening questionnaires have not been performed),” wrote Dr Sutapa Mukherjee of the ASA’s Clinical Committee.

“If the patient meets the appropriate screening questionnaire criteria the patient can proceed directly to the home based (12250) or laboratory based diagnostic sleep study (12203) without the need for prior professional attendance by the respiratory/sleep medicine practitioner.”

The Department of Health says it will be undertaking a 6-month and two-year review of claiming data for the new and amended thoracic items to see what impact the revisions have had on usage of sleep medicine studies.

The ASA said the changes and the recent Private Health Cover Gold/Silver/Bronze tier reforms have prevented many patients from accessing sleep studies in private clinics and this will put pressure on public hospital sleep clinics.

The ASA said it had met with met with senior advisors to the Federal Health Minister and also with private health insurance industry representatives about this issue “and will continue to advocate that these recommendations be reversed.”

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