An unsettling case: The impact of a drawn-out audit on the vulnerable

Jolyon Attwooll

24/02/2023 3:02:21 PM

Is a ‘rigid, inflexible’ compliance approach experienced by GPs treating some of society’s most at-risk patients damaging health equity?

Dr John Scopel
Dr John Scopel faced an extended audit, which affected the care he could deliver. (Image: Jake Pinskier)

Some of the most marginalised people in Australia have passed through the doors of Dr John Scopel’s consulting room.
As a GP who has worked in both inner Melbourne and remote Australia, he has treated many traumatised patients. Among them are refugees and asylum seekers who cannot speak English, Aboriginal and Torres Islander people, homeless people, as well as patients who inject drugs.
His work often overlaps with public mental health, alcohol and other drug services, the prison system, child protection and managing domestic violence.
Dr Scopel is clearly driven to treat people who may otherwise struggle to get the right healthcare, an approach he attributes to his parents.
‘They both demonstrated to me if other people don’t have access or rights, you try and see their perspective and help them get there,’ he told newsGP.
‘I work with a team who across the board have a deep motivation to address this need.’
It is the type of complex, involved care that is the antithesis of six-minute medicine, needing input from many different sources.
To pull the strands together, Dr Scopel decided to innovate, using case conference item numbers as a tool for managing and coordinating care.
Item numbers 735, 739 and 743, which are not commonly used due to the time required to make them work, can be used when a person has complex, chronic or terminal conditions, and when at least two other carers are involved who provide a different service.
They could include homeless outreach workers, refugee complex case support workers, case managers from the local mental health unit, representatives from the Hospital Admission Risk Program (HARP) and other clinicians, to give just a few examples.
‘Nearly all the case conferences I undertook were face to face, often using interpreters,’ Dr Scopel said.
‘It was a matter of us working together more efficiently. It really has had very good consequences for patients, they resulted in wellbeing benefits to our most vulnerable clients.’
He says he was using the process at one stage up to around three times a week.
The approach, however, made Dr Scopel a statistical outlier – and in 2018, he received a letter from the Provider Benefits Integrity Division at the Department of Health notifying him of an audit for those item numbers.
‘This pattern of claiming is different to your peers and the reason for the difference is not apparent,’ the letter read.
‘This pattern of claiming may indicate that services provided may not have met the legislative requirements which apply to [the] MBS items.’
The audit sent shockwaves through Dr Scopel and his colleagues, who work in an area of healthcare that is often run on a shoestring budget.
It was the beginning of a process that would stretch out almost four years, with auditors drilling deep into the detail, comparing progress notes with the time templates had been opened, as well as querying the way he had sought patient consent.
In his words, Dr Scopel spent ‘a hell of a lot of time’ explaining crashing software that could not cope with opening multiple files and templates at once, while digging out many email trails showing his processes.
He makes the crucial point that he conducted the case conference items for which he was audited when he was either salaried or working voluntarily, meaning that he had nothing to gain financially.
He raised the matter with his local Federal member and subsequently received support from the Federal member for Melbourne, Adam Bandt, who went into bat for him at the highest level.
There was a gap of almost two years after the initial investigation, giving Dr Scopel some hope that the audit had lapsed – but it was not to be.
With no warning, the correspondence began again in early 2022 – and this time the tone was relentless. Eventually he agreed to pay around a four-figure sum, while his employer covered a substantially larger amount for the work that was audited under his lead.
That organisation, while not wishing to be named, has reiterated its support for his ‘exceptional’ clinical work.
For Dr Scopel, who says his focus has always been on obtaining the best patient outcomes, it is not the cost of the process that bothers him so much as the impact on care.
Firstly, he notes that every moment of the considerable time he needed to address the audit took him away from the consulting room. He also says he now practises much more defensively and knows many of his colleagues have reacted the same way.
‘To the letter of the law, [the Department of Health] may be correct but it is ultra rigid,’ he said.
‘I appreciate there is a role for auditing, but across the board colleagues have questioned why they did not highlight concerns and offer a chance to demonstrate change. Instead, the focus appears to be upon creating fear and financial gain.
‘Auditors should be comparing me with doctors working only in similar situations or community health – and even then there would be a wide disparity expected on such an unusual item depending on support staff available at the health centre.
‘Instead of being supported to deliver care, we were penalised.’
Short-sighted approach’
RACGP Victoria Chair Dr Anita Muñoz shares Dr Scopel’s concerns.
‘I think this really comes down to a case of: just because you can, does it mean you should?’ Dr Muñoz told newsGP.
‘The finding against Dr Scopel came down to his omitting certain bureaucratic requirements of the item descriptor.
‘There is no doubt that the clinical services he provided met the intention of the case conference funding and was of enormous benefit to his extremely vulnerable patients.’
Dr Muñoz believes the work is likely to have prevented many outpatient appointments and visits to the emergency department.
‘To sanction on technicalities a GP who was pouring that much value into his patients and community is nonsensical and short-sighted,’ she said.
‘For the small number of dollars the MBS has clawed back, it has now caused a dedicated GP doing the hardest of community medicine to limit his services and offerings.
‘Those patients will now take more consults, more hospital visits and more resources to manage their needs.’
Dr Scopel knows he is not alone in the challenges he has faced – while many colleagues and fellow clinicians have echoed the concerns of the RACGP Victoria Chair.
Dr Muñoz also says other GPs coordinating complex care with similarly high-needs groups have reported being too scared to use the item numbers for fear of attracting the auditors’ attention.
‘I think those consequences need to be understood by MBS compliance,’ she said.
A spokesperson for the Department of Health and Aged Care (DoH) said they would not comment on Dr Scopel’s specific case ‘due to legislative privacy and secrecy arrangements’.
In response to a newsGP inquiry querying the strategy given the patients’ vulnerability and the complexity of the healthcare involved, they said the DoH is ‘required to comply with and implement laws as made by the legislature’.
‘The requirements of MBS services are determined under legislation,’ the spokesperson said.
‘This means that the department must deal with non-compliance with legislation that it becomes aware of, it can’t choose to address some instances of non-compliance and not others.’
The spokesperson said the DoH’s response to compliance concerns ‘is proportionate to the risk they may pose and uses a combination of treatments, including education and early intervention’.
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Dr Ikechukwu Chinomnso Onwuegbuna   25/02/2023 7:09:43 AM

Has any doctor ever been audited for billing in a manner resulting in substantially less fees than their "peers"? If not why not? Auditors are meant to detect those who are not in line with expectation, no? You must attend those webinars and seminars organised by the indemnity companies. This man is a hero, not a villain. But then I comment based on his side of the story. You must present a balanced story ie comment from the auditors for equity.

Dr Lester Mascarenhas   25/02/2023 8:39:52 AM

One of Mark Butler’s promises for primary care reform includes “Improved patient access to GP led multidisciplinary team care, including nursing and allied health”.
Dr Scopel has been doing exactly this through appropriate use of the case conference item number.
Why then has he been penalised?
It is hard to fathom the reasons behind this audit against Dr Scopel. It is indeed short-sighted and appears conter-productive both in terms of government expenditure on healthcare and in health outcomes.

Dr Christine Linnette Troy   25/02/2023 11:55:43 AM

Easy solution.
Decision makers sit in with the GP for an hour a day for a week and walk in their shoes. It will become pretty obvious what should be billed or not. Of course he is an outlier .. who else wants to do this work all the time!
Maybe recommendations can then be made to the Government on how time consuming and complex the organisation of team meeting for complex care can be, and how better to support the people at the coal face.
One GP doing the work of multiple organisations should be supported not persecuted.
This GP probably knows the solution to fix places like Alice Springs (in a micro way - translate to a macro system)..... you never know, probably because no one thinks to ask.
It's a shame we don't celebrate and learn from people with experience who are already doing the hard and stressful work with the poorest and most marginalised, and traumatised peoples in our country.

Dr Christine Linnette Troy   25/02/2023 11:58:40 AM

Medical students/ GP registers with hopes and dreams to change our country health for a better place will read this and think - "why bother"
People get into medicine to make people and communities better - it's the (successive Governments over 10 years) that has broken the dream, they have the power to fix it.

Dr Matthew Laurence Byrne   25/02/2023 4:47:49 PM

Dr Scopels treatment by the department was disgraceful. Stories like this have made me happy I took early retirement, unfortunately adding to the shortage of gps in our rural area but preserving my own wellbeing and sanity.

Dr John Anthony Crimmins   27/02/2023 4:05:02 PM

I was involved in the same item audit in exactly the same timeline as Dr Scopel and fought it using local members/letters from the RACGP/AMA and RACP (as all were quoted as suppotive members of the commitee advising the department in the letters I received) and after 4 yaers I paid $30 000.
At one tsgae a senior officer reduced that amont to $7000 but I had done nothing wrong and kept fighting.
I do 24/7 cover for intellectually disabled aduklts accross Sydney in their homes for the past 25 years and do case confrences on a weekly basis as my patients are modertae to severe.
The system has no appeal mechanism/no ombudsman and cannot be tested in court.
The RACGP were weak in their actual actions but now I hear I am not alone I feel much better.
I continue to do Case Conferences but use preloaded templates /do universal consents ect ect to play the game and it has nothing to do with quality.
RACGP must ask for an appeals mechanism that meets professional and Australian standards

Dr Mary Belfrage   1/03/2023 9:41:42 AM

It is such an indictment of our health system that those providing genuine person-centred team-based care for people with complex health and social needs are conspicuous as outliers: ‘This pattern of claiming is different to your peers and the reason for the difference is not apparent,’ the letter read. I would suggest that 'the reason for the difference not being apparent' reflects a lack of understanding of what it takes to provide effective and compassionate healthcare to people with trauma and complex needs. As well as the health economics of this being completely wrong re good primary healthcare preventing downstream health costs, it is especially appalling in the context of no personal financial gain.