Sleep medicine specialist repays $1.2 m for inappropriate item 12250 claims


By Michael Woodhead

12 Aug 2019

A sleep medicine specialist has been reprimanded by the Professional Services Review (PSR) and ordered to repay $1.2 million he received from Medicare for sleep studies under MBS item 12250.

The doctor, whose name has been withheld in the report by the Medicare claims watchdog, was also disqualified for six months from item 12250 (‘overnight investigation of sleep for a period of at least 8 hours of a patient aged 18 years or more to confirm diagnosis of obstructive sleep apnoea’).

According to the latest case outcomes released by the PSR director, the doctor failed to keep adequate records, failed to supervise the technician and scorer adequately and did not provide adequate clinical input into MBS item 12250 services.

In the July update, the PSR director gives examples of poor record keeping, such as the doctor using the date when the sleep investigation commenced for billing purposes rather than the date that he completed the service.

Examples of poor supervision include allowing sleep technicians to make cursory records of patient history and omitting significant conditions such as COPD, and failing to give more details than ‘blood pressure’ as a comorbidity.

Technicians also failed to record patients’ medication history, smoking and alcohol history, or make a record of the patient’s sleep position.

The PSR determination concluded that the doctor failed to meet the requirements of the 12250 item descriptor in not personally confirming the necessity of the investigation before it took place.

Investigators found that sleep technicians were allowed to decide to proceed with an unnecessary investigations when it was unlikely the patient had a high probability of OSA, or where there was insufficient information on which to make a proper assessment of whether the investigation was necessary.

“Tests were routinely performed at regular intervals without evidence they would alter management,” they noted.

Problems with the scored data received from sleep scorers were also highlighted in the PSR report.

“In some cases there appeared to be inconsistences in the arousal index and the recorded apnoeas, and in others the data appeared to be insufficient on which to make an assessment of the patient’s sleep stages.

“While the practitioner said he did raise issues with the scorers’ supervisor, there was no record in the cases reviewed by the Committee of him returning studies for further assessment. More concerning, there was no evidence that any of the practitioner’s Sleep Reports noted the inaccurate scoring or explained the effect this has had on the Sleep Report.”

The PSR report also found that the duration of the sleep study was often less than the required 8 hours.

Already a member?

Login to keep reading.

Email me a login link