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When the Professional Review Branch comes calling


Filip Vukasin


16/09/2022 4:18:52 PM

Dr Andre Leong thought he was performing a community service and saving the healthcare system money. The department disagreed.

Dr Andre Leong in clinic
Dr Andre Leong has been told to start charging patients privately for certain surgical procedures, or stop performing them altogether. (Image: Supplied)

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.’

Andre-Leong-article.jpgDr 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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Dr Ern Chang   16/09/2022 8:19:59 PM

Andre and I go back a very long way. As long as I have known him, he’s been a person of integrity, strong principles, with overwhelming compassion for patients he serves and treats. These traits are evidenced by many of his past and present community endeavours. These actions by Medicare are appalling. I hope justice prevails, and he can be allowed to return to providing a much needed service to his community.


Dr Dani Ray Buchanan   17/09/2022 7:34:49 AM

Such an shame. A very experienced and skilled GP leaving in such a way. He should be applauded for his work, not audited. The targeting is so short sighted. By stopping this man doing his work which would cost medicare, I am guessing, half a million a year, they funnel all of those patients, or at least 80% of them, intot he public hospital system at a cost of tens of millions. It is such stupidity that it is astounding.
PS - what is the RACGP doing to combat this sort of witch hunting on GPs. No wonder we are not getting the trainees coming through when the peak body representing us remains silent on these issues.


Dr Vivienne Ann Clark   17/09/2022 7:56:12 AM

And we wonder why young graduates do not want to enter General Practice.


Dr Sarah Marie Cunningham   17/09/2022 8:34:01 AM

What a terrible outcome for that community and Dr Leong.


Dr Chris Mirakian   17/09/2022 8:44:07 AM

This is such a ridiculous scenario. I know there are doctors who inappropriately claim item numbers and rort the system but anyone can see this is not the case here... in fact the complete opposite. Sadly I think medicine is not the career it used to be... especially general practice.


Dr Lucinda Gentle   17/09/2022 9:57:15 AM

This article needs to be released into mainstream media. All the patients commenting on other articles about “greedy doctors” need to see what the government does to doctors who work as charitably as this. We need to turn the conversation around and show that it is the system that is screwing over both doctors and patients alike. Why is there less bulk billing? Why are there less services provided in GP, in communities? Why do they have to travel further for their surgery and wait longer? The blame needs to rest squarely with the DoH, and ultimately the Minister.


Prof Max Kamien, AM. CitWA   17/09/2022 10:20:19 AM

That area of Perth has poor public health services. A former patient with severe neck pain has been on a pain clinic waiting list for over 12 months. His current GP has run out of options and seems unable to get him moved up the pain clinic waiting list. He tells the pensioner patient, "If you had private health insurance I could get you seen this week. But you don't." Problem unsolved. But it does confirm the reason for Dr Leong's motivation.


Dr James Edward McLeod   17/09/2022 11:11:10 AM

We're lucky to have such skilled and dedicated GPs like Andre working in Australia. At the end of the day these audits will only punish our patients by forcing our arm to cut services, bill privately and do private sector work.
If the government wants to save money why don't they stop throwing it down the bottomless pit of big hospitals? Fund community nurses, carers and home services better. Fund general practice better. Educate our kids and the community better. Treat people in the community and keep them out of hospitals!
Best wishes Andre keep up the great work.


Dr Bradley Arthur Olsen   17/09/2022 1:33:30 PM

Thank you for your service to the Australian public DR Leong, it seems the admin and bureaucrats have taken over medicine. I am facing similar problems here in Bundaberg. I will be leaving soon ,with Bundaberg base hospital to take over the many patients I keep from their doors


Dr Nicholas Heath Aalders   17/09/2022 2:15:03 PM

Maybe he should have just set himself up as cosmetic cowboy. Typical AHPRA going after the good doctors and letting he shoncks get away with manslaughter.


Dr Thilini Rathnadeepa Hettiarachchi   17/09/2022 2:33:22 PM

It’s a shame how actual fraud gets dismissed while great doctors are made at fault. All due to a faulty system


Dr Linh Tam Doan   17/09/2022 6:13:55 PM

I hope this article can go some way to support Dr Leong through what sounds like an arduous process. Hopefully common sense will prevail. It sounds like he does such incredible work that of course he is a statistical outlier. But what provisions are in place to prevent the PSR from unduly preventing access for care for his patients? I feel horrified and I think the public would feel horrified to hear of how General Practice is being reduced to impotence in our currently stretched health care system. This cannot fly.

Thank you Dr Leong and NewsGP for sharing this story. I hope there is more open media coverage so that the public is allowed to be appropriately angered for being cheated of their right to professional care at the coalface, without fuss, delay or undue cost.
I
Bless you Dr Leong and NewsGP for your good work for which you should be commended.


Dr Shew Ging Ting   17/09/2022 9:01:56 PM

I feel that Dr Andre Leong should be applauded for doing such good work. Many patients who need surgical treatments, but have no private insurance, need to wait for long time to get treatment from Public Hospital. It is hard to find a GP with such special skills. It will be sad if he has to leave GP practice because of the stress caused by being compassionate and not charging more.


Dr Stuart Crowther Burton   18/09/2022 10:00:07 AM

As a GP Anaesthetist in Kalgoorlie in the 80's I was the only such practitioner working in a regular practice and also doing elective and emergency anaesthetist. The MBS boffins (non doctor) of the day flew to Kalgoorlie to visit me and ask the question "Why are you you the highest user of anaesthetistic item numbers of all your colleagues in the area?". I replied it might be something to do with the fact that I was the only GP Anaesthetist in town. After this 10 minute interview they flew back to Perth!! Some things never change. I wish Dr. Leong well and suggest he "stick to his guns". Otherwise public servants win.


Dr Arlene Nicol Suttar   19/09/2022 6:41:24 AM

He was contacted by DoH, which is Federal funding of health . These public servants have done their job and done it well as now there will be less cost to the commonwealth health budget . The costs will be transferred to the state health budget as the patients will have to go public . This story has nothing to do with logic but everything to do with cost shifting..yet again .


Dr Peter JD Spafford   19/09/2022 8:30:48 PM

Medicare undervalues all services, hence the need for a "gap" fee by specialists. It is not anything but a health insurance but unfortunately still one that patients think pays the bill. This case is not about his ability to perform the procedures and should never have been undertaken by the DoH, or AHPRA.


Dr Julian Hadden Fidge   20/09/2022 3:23:51 PM

I did just stand for President of the RACGP, and part of my platform was addressing the psr and ahpra. There's not a great deal of interest in this area, and I think this is one of the reasons why GP is declining. Essentially, we are being forced into NOT providing services because any good deed goes unpunished.
In my case, I have been working in AOD rehabilitation for 40 years and I was investigated because the average age of my patients in rehab is lower than the average age of my patients in my GP. I nearly stopped attending the rehab facility I was so offended.
True story.
Julian


Dr Peter Thomas Ryder   22/09/2022 2:58:20 PM

Note to new RACGP president: PLEASE take on this issue! Not just this case , but the entire behaviour of the PSR. Are those bureaucrats giving ’value for money’ ? The colleges need to push back harder & continuously.


Dr Atul Misra   25/09/2022 2:11:09 AM

Medicare undervalues all services, hence the need for a "gap" fee by specialists. It is not anything but a health insurance but unfortunately still one that patients think pays the bill. This case is not about his ability to perform the procedures but else??