Specialists warned over ‘unjustified’ requests for diagnostic imaging

Specialists have been warned against making unnecessary requests for imaging, with the Medicare watchdog saying it may reject MBS claims for imaging without proper clinical justification.

The message from Professional Services Review follows a string of cases where practitioners were ordered to repay Medicare rebates claimed for consultations where diagnostic imaging was ordered.

In one case earlier this year, a GP was ordered to repay $290,000 and was disqualified from providing two MBS items after admitting a string of failings, including initiating diagnostic services without a clinical indication.

“For example, in the reviewed records for diagnostic imaging services, these services appeared to be initiated without undertaking relevant examinations or obtaining a sufficient patient history,” the agency found.

With a number of specialists also coming before the watchdog in recent months, PSR director Professor Julie Quinlivan said there was a broader issue.

“The PSR has recently seen cases where X-rays have been ordered without a prior history or examination being recorded,” she said in her final newsletter as agency director this week.

“Clinicians should be mindful that X-rays cause exposure to radiation, and every X-ray request should be clinically indicated to either confirm a diagnosis or progress management.”

“Imaging should be confined to the body part identified by history and examination.”

She added: “Imaging is not a substitute for a history and examination. Finally, undertaking multiple X-rays for screening purposes, or at each visit, may cause patient harm.”

It’s not the first time the agency has launched a crackdown on excessive use of diagnostic imaging, although research suggests its previous attempts have been met with mixed success.

Back in 2009, the agency sent letters to 50,000 practitioners warning against the use of CT screening for lower back pain and detailing a number of recent cases where doctors had been peen penalised for overtesting.

An analysis published in BMJ Open this year showed this report was followed by an immediate reduction in scans of around 440 per 100,000 people.

However, growth in use soon resumed and returned to pre-intervention levels within 18 months.

“This suggests that although such actions may be influential, any resulting changes in behaviour may not be sustained in the absence of ongoing intervention,” the authors wrote.

Writing in the newsletter, Professor Quinlivan also sounded the alarm over what she termed the “failure” of some doctors to secure full consent for surgical procedures.

“In some recent cases at the PSR, practitioners have routinely billed patients for multiple surgical procedures when the medical records, consent forms and hospital documentation did not indicate that consent was secured for the additional billed surgical procedures,” she wrote.

“If a practitioner plans to perform several surgical procedures at one time, then each procedure should be discussed, and patient consent secured.”

These discussions needed to involve a canvassing of “all relevant treatment modalities and their advantages and disadvantages, as well as specific patient concerns,” for MBS item requirements to be satisfied, she said.

“Consent is a patient-oriented process.”

“Practitioners are reminded that if a major surgical procedure is billed, then smaller procedures that are integral to, or part of, the larger procedure cannot also be billed as every MBS service is a complete service.”

Over the three months from April to June, the PSR received 36 new cases, including three involving practitioners who had been previously referred, and finalised 22, Professor Quinlivan said.

She said a total of $5,456,234 in repayment directions were made from the finalised matters, with 16 practitioners receiving some form of restriction from using Medicare or the PBS.

What can happen if the PSR determines imaging has been requested inappropriately?
PSR executive officer Bruce Topperwien told the limbic:

Section 106U provides that the Determining Authority (DA) may issue a direction for repayment of benefits by the person who requested the diagnostic imaging service even if the person under review was not paid the benefit.

In practice, this does not often happen. That is, a finding of inappropriate practice in requesting diagnostic imaging rarely results in a direction to repay the diagnostic imaging benefits. Usually the only outcome is a reprimand and counselling, but in some cases a small part of the diagnostic imaging benefit is directed to be repaid by the requester of the service.

Nevertheless, in unusual cases where there is reckless or systemic inappropriate practice in requesting imaging, or it appears that, contrary to the law, the requester of imaging gets a personal benefit from the imaging, it is open to the DA to order repayment of the whole benefit.

If it is only the initiation (that is, the requesting) of diagnostic imaging services that is the subject of the review or investigation by PSR, then any benefit paid in respect of the attendance service at which the imaging was requested cannot be recovered. However, if the attendance services are the subject of the review or investigation by PSR, then inappropriate requesting of diagnostic imaging services might lead to a finding that the practitioner’s conduct in connection with the attendance service would be unacceptable to their peers, and the Determining Authority could order repayment of the benefit for that attendance service.

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