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Overservicing - medical practitioner to repay $120,062.90



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FROM THE ACTING MINISTER FOR HEALTH THE HON. BARRY JONES U ^

OVERSERVICING - MEDICAL PRACTITIONER TO REPAY $120.062.90

A medical practitioner has been ordered to repay $120,062.90 he received in respect of medical services he rendered which were found by a Medical Services Committee of Inquiry to be excessive.

The Acting Australian Minister for Health, Mr Barry Jones, said today the medical practitioner, Dr Anthony Joseph of 60 Cook Street, Lithgow, NSW, has been required to repay the money to the Commonwealth and the Western District Medical Benefits Fund.

The money represented the amount of medical benefits paid in respect of services rendered by Dr Joseph which were found to be not reasonably necessary for the adequate medical care of the patients concerned.

"The Government is seriously concerned at the practice of doctors who provide services not reasonably necessary," Mr Jones said.

"Excessive services are a significant drain on public funds, and every effort is being made to reduce the magnitude of the problem." A statement has been tabled in the Parliament detailing particulars of the Ministerial determination which required Dr Joseph to repay:

. $118,558.15 to the Commonwealth; and . $1,504.75 to the Western District Medical. Benefits Fund.

Emphasising the Government's view that people who·need medical services should receive them, Mr Jones said there was a clear division between necessary services and services not reasonable required for the medical care of a particular patient.

"A very fair and equitable peer review system exists to distinguish between the two situations," the Acting Minister said.

Mr Jones explained that Medical Services Committees of Inquiry, which function in each State, inquire into suspected excessive professional services by medical practitioners.

The committees, which make recommendations to the Minister for Health, could recommend that a doctor be reprimanded, counselled, and ordered to repay the amount of medical benefits involved in services identified as excessive.

The committees comprised five medical practitioners of whom four were nominated by the Australian Medical Association.

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Mr Jones emphasised that doctors subject to Ministerial determinations following Committee of Inquiry reports could seek a review by a Medical Services Review Tribunal.

nI.t is the Government's intention to continue to pursue with the utmost vigour those doctors who provide excessive services.." "Details of the considerable progress which has already been made and the action planned for the future to deal with medical

excessive servicing was provided in the statement to Parliament by the Minister for Health on 15 November 1983»” Mr Jones said.

The Acting Minister said that any doctor who sought to misuse the health benefits system must expect to become subject to public scrutiny. .

NOTE: Commonwealth Gazette extract attached.

CANBERRA 11 May 1984

Commonwealth of Australia Gazette No. G 17, Tuesday, 8 M ay 1 9 8 4 Published by the Australian Government Publishing Service, Canberra GENERAL

Health

C O M M O N W E A L T H O F A U S T R A L IA H ealth Insurance A ct 1973

S T A T E M E N T U N D E R S E C T IO N 106aa

O N the tw elfth day o f July 1982, the Hon. James Joseph Carlton, M .P „ the M inister o f State fo r Health at that time, made a determination under section 106 o f the H ealth In ­ surance A ct 1973 in respect o f D r A nthony Joseph, o f 60 Cook Street, Lithgow, New South Wales. The determination was varied by the Medical Services Review Tribunal on the twentieth day o f December 1983.

Particulars of Determination A copy o f the initial determination is annexed hereto, marked ‘A ’. This determination was varied by an Order on Review o f the Medical Services Review Tribunal, which substituted fo r the amounts therein, to be paid by D r Joseph, the following amounts:

Am ount: Payable to:

$ _

118 558.15 Commonwealth o f Australia 1 504.75 Western D istrict M edical Benefits

Fund

120 062.90 Total

The determination that D r Joseph be reprimanded was affirmed by the Tribunal.

Reasons for Determination

The in itia l determination was made by the form er M inister on the basis o f a report made under sections 104 and 105 o f the H ealth Insurance A ct 1973 by a Medical Services Committee o f Inquiry for the State o f New South Wales after its inquiry into the practice o f D r Joseph.

The Committee stated that:

‘ From the outset the Comm ittee’s consideration o f this ref­ erence has been complicated by the absence o f adequate c lin i­ cal details on each o f the patients under reference. Despite D r Joseph’s in itia l unwillingness to supply clinical details

(Exhibits 8 and 9), the Committee ultim ately acquired a total o f eighty exhibits (in respect o f 64 patients) related to the medical condition o f the patients under reference . . .’

‘ In its consideration o f this m atter, the Committee was com­ pelled to rely almost exclusively on evidence provided by D r Joseph during the hearings. W ith only this verbal evidence upon which to rely in most cases the Committee has been pre­ sented w ith the problem o f determining the extent to which each o f the 13 990 services under reference could be deemed

reasonably necessary for the adequate medical care o f the patient concerned . . .’

‘In considering each individual service provided to each o f the patients under reference, the Comm ittee has used its ex­ pertise, as well as the clinical notes and verbal evidence given by D r Joseph, in endeavouring to determine which services should be accepted as being reasonably necessary for the ad­ equate medical care o f the patients concerned’.

The Committee was o f the unanimous opinion that, in re­ spect o f the 153 patients under reference, certain o f the ser­ vices were excessive as they were not reasonably necessary for the adequate medical care o f the patients concerned. The ser­ vices represented 86% o f the services under reference.

Accordingly, the Committee recommended that amounts o f $120 836.65 and $2603.50, representing medical benefits paid in respect o f the services which the Committee con­ sidered to be excessive, be paid by D r Joseph to the Common­

wealth o f Australia and the Western D istrict Medical Benefits Fund, respectively. The Committee also recommended that D r Joseph be reprimanded. '

The former M inister accepted the findings and recommen­ dations set out in the Comm ittee’s report and made a determ i­ nation accordingly.

Following notification o f the determination, D r Joseph requested a review o f the determination by the Medical Ser­ vices Review Tribunal under section 114 o f the Health In- suranceAcL. ...

The request was made on the follow ing grounds:

‘ (i) That the Medical Services Comm ittee o f Inquiry (hereinafter referred to as “ the Com m ittee” ) failed and declined to inform itself o f all relevant evidence reasonably available to it before expressing its opinion in its report to the M inister o f State fo r Health, as

required under s. 104 o f the A ct. .

(ii) That the Committee failed to establish the particular . circumstances o f each relevant patient o f D r Joseph and therefore erred in concluding that the services ren­ dered were excessive w ith in the m eaning o f

s. 79 (1B) (a) o f the Act.

(iii) That the Comm ittee erred in making its assessment o f what was a reasonable assessment o f an adequate number o f services in that it failed to allow fo r emerg­ encies and other contingencies associated w ith medical practice.

(iv ) That the Comm ittee erred in its findings as to the dis­ tances covered by D r Joseph in the conduct o f his practice.

(v ) That the Comm ittee erred in its findings as to the dates o f certain services.

(v i) That the Comm ittee erred in drawing inferences against D r Joseph w ithout examining all available witnesses.

(v ii) That the Comm ittee erred in calling upon D r Joseph to adequately demonstrate that services were reason­ ably necessary fo r the adequate care o f the relevant patients w ithout establishing services rendered were excessive by reference to all reasonably available evidence.’ .

Pursuant to sections 115 and 119 o f the A c t, the Tribuna l con­ sidered D r Joseph’s request fo r review.

The T ribuna l concluded that:

‘The picture presented is o f the practitione r calling on the patients on his regular rounds, listening to the patient’s heart, listening to the patient’s chest, taking the patient’s blood pressure and w ritin g a prescription when required, all, as it were, as a package o f reassurance o f a frequency far exceeding the bounds o f what was reasonably necessary fo r the adequate medical care o f the patient concerned.’

A fte r a lengthy and careful review o f the documents fo r­ warded to it, the Tribunal found that, in all but 399 o f the total number o f 13 990 services under reference, there were no grounds to alter the determination. The M S R T found that those 399 services were not excessive services w ithin the meaning o f the H ealth Insurance Act.

Accordingly, the decision o f the Tribunal on D r Joseph’s re­ quest fo r review was that the initial determ ination be varied by substituting fo r the amount o f $120 836.65 payable to the Commonwealth the sum o f $118 558.15, and fo r the amount o f $2603.50 payable to the Western D istrict Medical Benefits

Fund the sum o f $ 1504.75. The Tribunal affirmed that part o f the determ ination that D r Joseph be reprimanded.

Comments The Governm ent is seriously concerned at the practice o f doc­ tors like D r Joseph who provide services which are not reason­ ably necessary fo r the adequate medical care o f their patients.

Excessive services are a significant drain on public funds and every effort is being made to reduce the magnitude o f the problem.

It is the G overnm ent’s intention to continue to pursue w ith the utmost vigour those doctors who provide excessive ser­ vices. Details o f the considerable progress which has already been made and the action planned fo r the future to deal w ith medical excessive servicing was provided in my Statement to

Parliament on 15 November 1983.

A ny doctor who, like D r Joseph, seeks to misuse the health benefits system must expect to become subject to public scrutiny.

Dated this 30th day o f M arch 1984.

N E A L B L E W E T T

M inister o f State fo r H ealth