Feature

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When the Professional Review Branch comes calling

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For Dr Andre Leong, it was a normal day in early May 2022 at his Warnbro clinic when a phone call came through from an unknown person.
 
The man on the other end of the line was from the Department of Health and Aged Care (DoH), and said he was calling to find out about Dr Leong’s clinic demographics.
 
Dr Leong had been investigated briefly by AHPRA several months prior, relating to a complaint from a patient that was later dismissed, so he was confused by what this call was about.
 
He specifically asked the man if this was an audit, to which he was told, ‘no, just a friendly chat’.
 
After a brief discussion, Dr Leong and the man – also a GP when not working for the DoH – organised to have a follow-up conversation three weeks later.
 
About 10 days after the cold-call, Dr Leong received written information from the department’s Compliance Enforcement and Professional Review Branch, informing him that the upcoming scheduled phone call would indeed be an audit.
 
He prepared as best he could for that phone interview, which lasted two hours.
 
‘The phone call was like an exam, asking what I billed, what my interpretation was of certain item numbers and going through each one, but I didn’t realise that would happen and wasn’t prepared for it,’ Dr Leong told newsGP.
 
‘And it wasn’t just that. He grilled me about my prior training and where my hospital placements were, from years ago.
 
‘I was shocked.’
 
The interview was precipitated by the fact that Dr Leong was billing item numbers that ranked him highly among his peers.
 
Later correspondence from the DoH showed that he ranked:

• fourth among GPs for the rendering of MBS item numbers 721, 723 and 2521 in association (chronic disease management)
• first among GPs for services rendered related to regional or field nerve blocks
• first among GPs for item numbers 18264 and 32138 in association (haemorrhoidectomy)
• first among GPs for plastic and reconstructive surgical operations, such as ptosis correction.

That he ranked highly, particularly in relation to surgical procedures, did not come as a surprise.
 
Dr Leong undertook medical training in Singapore, served in the military and has experience as a field surgeon. His skills also increased exponentially after he led a medical team to Aceh, Indonesia, in the immediate aftermath of the 2004 Boxing Day tsunami.
 
‘Aceh was going for independence [at the time], so on top of the tsunami there was rebel fighting. It was mayhem, like a warzone,’ he said.
 
‘We spent the first few days just finding survivors who were mostly kids whose parents had died.
 
‘The main job was doing amputations. It was very stressful, particularly doing it on kids. Instead, I wanted to do something in my life to help kids, so later I switched and decided to be a GP.
 
‘As a GP, I see the broad spectrum of medicine, compared to doing plastics or orthopaedics.’
 
Dr Leong subsequently came to Warnbro, Western Australia, attained Fellowship and examined for the RACGP, taught medical students and has stayed in the same medical practice ever since.
 
As a result of his extensive experience, he performs operations that many GPs do not, such as haemorrhoidectomy, carpal tunnel release, ptosis correction and blepharoplasty, tendon repair (ie for Dupuytren’s contracture), and skin cancer surgery and repair.
 
The services are not advertised, and Dr Leong only operates on patients who have been referred to him. All operations are bulk billed and no one pays a gap – despite him describing the rebates as ‘quite pathetic’.
 
‘For example, a carpal tunnel job attracts a rebate of $248 – barely worth the 90 minutes [of] my time, nurse’s time, OT [occupational therapy] equipment maintenance, etcetera to make it worthwhile,’ he said.
 
‘But we’ve been persevering because our patients need this service.’
 
GP Dr Alvin Wee regularly refers to Dr Leong, telling newsGP the patients are typically people with no private health insurance, who cannot afford to see a private plastic surgeon, orthopaedic surgeon or hand surgeon, or those who are unable to travel long distances, such as the elderly and frail.
 
‘Andre used to get word-of-mouth referrals from the orthopaedic clinic in Fremantle Hospital/Rockingham Hospital for carpal tunnel surgery when they could not cope with the backlog of patients,’ he said.
 
‘The treating RMO/specialist [would say], “I’ll put you on the waiting list but go see Dr Leong in Warnbro as our waiting list is too long”.
 
‘Andre bulk bills everyone and it is a “no brainer” that that eliminates the cost factor for patients accessing medical [and] surgical care.
 
‘He was there to help our patients out when the system couldn’t.’
 
Dr Shiree Treleaven is another GP who often refers to Dr Leong.
 
‘Many of my patients are not privately insured, so accessing a private surgeon is not an option for them,’ she told newsGP.
 
‘He offers a service … unlikely to be offered by other GPs. Not only do I refer patients to him for these services, but other GPs also [do].’
 
These referrals were not just restricted to GPs. In 2020, Dr Leong noticed a wave of patients being referred to him for senile ptosis by optometrists and pre-emptively wrote to Medicare to ask for clarification and support.
 
‘The concern I now have is that I am reasonably certain that no other GPs in my area would be doing this surgery and my billing claims for this particular procedure would definitely deviate from the norm, and I would be flagged up for audit,’ part of his email to the Professional Services Review (PSR) and DoH read.
 
‘I still vividly remember how stressful the last audit had been, and needless to say, I’m keen to avoid having to go through another one.’

Dr Andre Leong runs a charity that provides medical services to Cambodian villages, but is considering retiring as a GP due to the stress. (Image: Supplied)

Dr Leong’s prior audit was several years earlier and resulted in him having to pay back $600. He has not been subjected to any other compliance activity or investigations.
 
However, despite proactively seeking advice on his billing, the DoH response did not address Dr Leong’s specific concerns.
 
‘The AskMBS advice service … provides guidance on the interpretation and application of the Medicare Benefits Schedule items, explanatory notes, and associated legislation,’ part of the response read.
 
‘While it is located in the department’s Provider Benefits Integrity Division, AskMBS has no role in the division’s direct compliance function – that is, the identification of compliance issues and the prosecution of compliance action in relation to those issues.
 
‘AskMBS’s role is pre-emptive; it seeks to assist health professionals and practice managers with the appropriate claiming of MBS items so that compliance issues do not arise.
 
‘Where there is any doubt about the appropriateness or clinical relevance of a particular medical service, it may be appropriate to seek the support of the relevant medical profession prior to claiming a Medicare benefit for the service.’
 
When Dr Leong mentioned his prior compliance experience and the 2020 email correspondence during the two-hour phone interview, the DoH GP said he had no knowledge of it.
 
The way the phone call ended was, from Dr Leong’s perspective, unpleasant.
 
‘He said to me at the end, “I can’t figure out if you’re a keloid or amelanocytic melanoma”, which I interpreted as him saying I was a wolf in sheep’s clothing,’ he said.
 
Two weeks later, Dr Leong received a written summary from DoH stating that he had not provided enough information to resolve the matter.
 
When he called the interviewer to clarify, the conversation was short, and the DoH GP reiterated the letter’s findings that Dr Leong either needed to start privately charging patients or cease providing the services within six months.
 
He has since stopped accepting new referrals and will only honour existing bookings for the coming weeks.
 
‘I struggle to see this whole spectacle in any way other than Medicare embarking on another near-sighted cost-cutting measure that is failing us doctors and patients,’ Dr Leong said.
 
‘I thought that through all these years that I’ve been doing these surgeries at … rebate rates, I would have saved the health department a tonne of money [by] keeping patients out of hospital.’
 
When approached for more information on the department’s compliance measures, a DoH spokesperson told newsGP it protects Australia’s health payments system through the prevention, identification and treatment of incorrect claiming, inappropriate practice and fraud by healthcare providers.
 
‘Health provider compliance activities are conducted through a series of interactions between the department and health providers or their representative through written correspondence, telephone calls or meetings,’ the spokesperson said.
 
‘When telephone contact is undertaken, departmental officers always introduce themselves and explain the purpose of their call.
 
‘Health providers subject to compliance activities will receive written correspondence from the department.’
 
The spokesperson also said the Practitioner Review Program (PRP) is the only compliance measure that is conducted over the phone, as was done with Dr Leong.
 
‘Under the PRP, a practitioner is normally offered several opportunities to respond to any identified concerns and to explain their practice,’ the spokesperson said.
 
‘Practitioners are also able to discuss their case with a qualified health professional. Where concerns are unable to be resolved under the PRP a practitioner may be referred to [the] Professional Services Review.’ 
 
When asked if the DoH and AHPRA work together on these audits, the spokesperson said they ‘perform separate and independent functions’ but may refer to one other if relevant.
 
Dr Michael Wright, Chief Medical Officer at Avant and a Sydney GP, encourages doctors targeted for review to contact their medical defence organisation for assistance as soon as possible.
 
‘As a GP, I know many of my colleagues have found Medicare compliance activities a significant source of stress,’ he told newsGP. 
 
‘This has been a growing area of concern for Avant. We have also seen an increase in compliance activities in recent years, which has added to this stress.’
 
In Dr Wright’s experience, the ‘vast majority’ of Medicare non-compliance tends to be inadvertent and related to a misunderstanding or lack of information.
 
‘There is no single source of education about Medicare’s requirements that doctors can complete when they start practising and subsequently to keep their knowledge up to date,’ he said.
 
‘There would be great benefit in this given the complexities of the system and given that managing Medicare and practising within its requirements is an essential aspect of delivering high-quality patient care.’
 
It is not just GPs who can be impacted by these compliance activities. With Dr Leong closing his surgical books, patients he would have previously seen will now be referred to the public health system or forced to pay privately.
 
‘The current waiting time to be seen by the plastics team is about a month, and surgery within 2–3 months of my referrals,’ Dr Wee said.
 
‘Andre’s accessibility meant that my patients did not wait for more than six weeks from the point of referral to surgery.’
 
They will also now need to travel further afield to access care.
 
‘It’s probably okay for those with good family support or those who can afford it, but for those who can’t, this will further clog up our public health system,’ Dr Wee said.
 
‘Andre bulk bills everyone. He saves a huge amount of money for our patients.
 
‘For skin cancer lesions, most plastic surgeons are charging about $1000–1500 out of pocket for a graft or flap on the nose or face. For carpal tunnels, depending on who you can get in to see, they are about $800–3000 out of pocket.’
 
For Dr Leong, these developments are not only a concern for himself and his patients, but also the up-and-coming GPs he trains.
 
‘There are no incentives for them to learn these procedures,’ he said. ‘We are seeing the sunset of GPs doing surgical work.’
 
Spurred by his experiences in Aceh, Dr Leong runs a charity that provides medical and dental services to Cambodian villages and runs a local charity for disadvantaged kids in WA, but is considering retiring as a GP due to the stress.
 
The end of Dr Leong’s medical career would likely have a domino effect in his community, but eventually may prove necessary for the sake of his own health and wellbeing.
 
‘I’m not expecting a medal or trophy,’ he said. ‘I just don’t want to be labelled a fraud.’
 
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compliance Medicare Practitioner Review Program

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