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Questions Remain Unanswered on Strike Rate Against Doctors

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During the June Estimates, I asked the Professional Services Review Scheme (PSRS) why there was a 100% strike rate against doctors. I was informed that only a small number of cases make it to the Committee stage after several preliminary steps.

The representative assured me that the system is fair, although she admitted that appeals are restricted to procedural issues and cannot address the merits of the evidence.

While she mentioned that the Committee consists of the doctor’s peers, she did not address my concern about the 100% strike rate.

Transcript

Senator ROBERTS: Thank you for appearing again today. At previous estimates, I was told that administrative investigations of doctors conducted by the Professional Services Review Scheme were done in a completely fair manner. Your annual reports reveal that, since 2008, there have been 173 doctors who faced administrative investigations by committees leading to sanctions. How many of those prosecutions were successful, leading to sanctions being placed upon doctors, including suspension of practice?  

Mr Topperwien: The 173 practitioners that you refer to were the ones who were referred to committees after a long process. We’ve in fact been asked to look at over 1,800 practitioners. Those 173 were ones out of the 1,800 that we’ve looked at that the director would have had concerns that there was a possibility that they had engaged in inappropriate practice. That concern that the director would have had for each of those cases would have followed an exhaustive process by which they would have looked at samples of their patient records, interviewed the practitioner, looked at the submissions that had been made and then formed the view that for each of those practitioners there was a chance that they had engaged in inappropriate practice. They were not prepared, probably for most of them, to enter into an agreement or the director was so concerned about what looked like their conduct that they thought it ought to go to a committee of their peers to fully investigate what had actually gone on. So the small number of practitioners who end up going to a committee have gone through an exhaustive process prior to even getting there. And, as I said, they came out of 1,800 practitioners.  

Senator ROBERTS: Thank you. As I said, there have been 173 doctors who have faced administrative investigations by committees, which is what you’re confirming. I’ve asked you how many were successful. You said 100—  

Mr Topperwien: I’m aware that there have been practitioners who have gone to committees where there has been no adverse outcome for them.  

Senator ROBERTS: My understanding is that the number of those who were suspended were 171, not including two doctors who passed away.  

Mr Topperwien: I’m unable to confirm here and now what those numbers actually are, but I can take that on notice and get back to you with the actual numbers of cases that have gone to committees and, in broad terms, the nature of the outcomes of those cases.  

Senator ROBERTS: Thank you. I’d be happy with that on notice. But my understanding is that, as I said just then, the number of prosecutions that were successful for the review scheme, out of 173, were 171, not including two doctors who passed away. So that’s a strike rate of 100 per cent against the doctors.  

Mr Topperwien: Of those who went to committees.  

Senator ROBERTS: That’s what I’m—  

Mr Topperwien: Of the 1,800 that we started looking at in the first place, those 1,800 came from many thousands that were first examined by the department.  

Senator ROBERTS: I accept that. I accept the 1,800 and 173. But, of the 173, there was a 100 per cent strike rate against the doctors. I went to a barrister to check this out—a reliable barrister who used to teach in constitutional law as well as practice and worked in administration for governments. This finding is an extraordinary result, because no court system goes even close to a 100 per cent conviction rate. How can the scheme claim a fair system with a 100 per cent rate of finding against doctors?  

Dr Mahoney: Would it help if I gave some extra context around the cases that come to Professional Services Review?  

Senator ROBERTS: I just want to know the answer to the question. How can a system claim to be fair when it’s a 100 per cent strike rate?  

Dr Mahoney: If I give you the context around it, that will explain it. The department may wish to add to what I’m saying, but there are a whole range of compliance activities that are undertaken by the Department of Health and Aged Care. We talk about a pyramid. You may have heard of it. At the bottom of the pyramid, the very largest number, are the practitioners who get an educational activity helping them to understand why their billing might need to be looked at or how to bill correctly. The next step above that are what are called targeted letters, where practitioners who have been identified as perhaps needing a little bit more help will get a letter that gives them some information about their own data and just asking them to look at it. That’s really all those letters do. The next step that the department has in place is an audit program. 

Senator ROBERTS: What’s it called?  

Dr Mahoney: Audit.  

Senator ROBERTS: Thank you.  

Dr Mahoney: That sometimes gets confused with other activities. But the audit program, again, is very specific. It’s done by the department. I can talk about this because my previous role was exactly in doing the work with the compliance section of the department. With audit, it’s very specific. Again, it’s particular Medicare item requirements that can be audited, as in, ‘Did you do a specific thing?’—was there a referral, for example, for a service that requires a referral. The team that do the audit work, that’s what they do. They ask a practitioner to send in a set of documents with the proof that they’ve met a requirement. That’s a compliance activity. They’re the next level up in the pyramid. Then we come up to what’s called the Practitioner Review Program. That Practitioner Review Program is going up the pyramid where the concerns about the practitioner’s billing data or prescribing data is of more concern than any of those lower levels. That, again, is a much smaller group. For those practitioners, their data is looked at very thoroughly by senior medical practitioners who are experienced in practice as well as in looking at this data. If those practitioners think that there needs to be some intervention—the department’s medical staff—then that practitioner is contacted. They are given their billing data. They are given an opportunity to have an interview with one of the medical advisers in the department. The outcomes of those—there are three possible outcomes. The first is that the practitioner has explained their billing data, it makes sense and there is no further action taken. The second, and this is by far the largest group, is where there is some concern. The practitioner is given education about why there is concern with their billing and they are given what is called a period of review to change or to make changes to what the issues are. Then their data is looked at again. Again, the majority of practitioners understand that. They take that on board, they learn it and there’s no penalty. This is all what’s gone on before anybody gets to PSR. The third possible outcome for cases that are of really serious concern to the medical advisers in the department is that those cases are referred to Professional Services Review for the next stage up the pyramid. So we’re getting quite close to the top now. The only ones above us are those that are outright fraud that we don’t deal with. That’s not compliance. I need to add a little bit to that. After interview, a very small number of practitioners will go straight—will get referred to PSR because of the level of their concerns. A small number of practitioners who are given that six-month period of review do not make changes and they may go to PSR as well when their data is reviewed after six months. Then there’s the third group of practitioners that are referred to Professional Services Review. As you would know, under the 80/20 and 30/20 rules, if a practitioner breaches those then the department’s required by law to refer those cases to Professional Services Review. So the only cases that we are looking at in Professional Services Review are those that have already been through all of that and they are near the top of the pyramid. So that’s the context around the numbers that you’re talking about. The further context, as Mr Topperwien has said, is that even of those that get to Professional Services Review, only a small number go to committee. So I hope that helped.  

Senator ROBERTS: That has. It’s confirmed some of my fears, but I’ll explain that in a minute if we need to. Isn’t this strike rate of 100 per cent of those who get referred to a committee indicative of a system loaded against doctors with little or no chance of a doctor being able to raise a fair defence to allegations made?  

Dr Mahoney: No. They have chances right through the whole process, as I’ve described, or all the processes at the department of health.  

Senator ROBERTS: I got that. You’ve given me the answer—it’s no, in your view.  

Dr Mahoney: At Professional Services Review, they again have chances to explain, describe and discuss.  

Senator ROBERTS: The system is loaded against doctors, in our view, having listened to some doctors and consulted legal advice. Is it because in the process there’s no meaningful opportunity to challenge or explain the evidence being given against the doctor? My understanding of legal practice, which is pretty limited, is that there are two aspects. A case has to be taken through the process properly. If it’s not taken through the process properly, it’s dismissed. But if it’s taken through the process properly, then they consult the evidence. If the evidence is sound, there’s a conviction. If the evidence is not sound, it’s dismissed. So process has to be followed and evidence has to be strong. Now, doctors cannot appeal the merits of the evidence. They can appeal the process. So your process is fine, but they can’t appeal the evidence. Is that correct?  

Mr Topperwien: I’d just say here that the practitioner has multiple opportunities at the PSR end of the process to challenge the evidence, bring their own evidence and have their own witnesses. They have a lawyer in virtually every case, and the evidence that is the—the substantive evidence on which the committee makes findings is the doctor’s own practice notes. It’s the doctor’s own evidence that shows that they have engaged in inappropriate practice. They have every opportunity to put other evidence if they choose to. 

Senator ROBERTS: Isn’t it correct that a result of the process is that appeals are limited to arguments about process and not about merit or evidence of the case?  

Mr Topperwien: They have an opportunity to take an action in the Federal Court at any stage of the process about whether we have acted fairly and have taken into account irrelevant considerations. We’ve not taken into account irrelevant considerations. Those are the bases on which a challenge may be made in the court.  

Senator ROBERTS: So, as I said, the doctor can appeal the process but not appeal the merits of the evidence.  

Mr Topperwien: That’s right.  

Ms Shakespeare: Senator, perhaps I’d add some more context about the scheme—the PSR. Where people are referred to committees, that’s a committee of their clinical peers that hears evidence and makes recommendations and determinations about their clinical practice from a place of clinical expertise.  

Senator ROBERTS: In theory that’s correct. But in practice it’s not.  

Ms Shakespeare: I don’t think we would accept that either.  

Senator ROBERTS: Okay. At the next Senate estimates maybe we can talk further—or maybe before then if you’d be willing to. Would you be willing to engage in a conversation before then?  

Ms Shakespeare: About the makeup of committees for the PSR? I think that’s probably something that we would be able to engage in.  

CHAIR: Senator, via the minister’s office we can seek a briefing for you.  

Senator ROBERTS: Minister, an earlier review of the scheme said the scheme must be overhauled to make it fair and allow appeals to be made on merit. What’s your government’s timetable for a review of this system?  

Ms Quinn: Senator, there have been a number of reviews conducted around the Professional Services Review. You would understand that it’s established under the Health Insurance Act, so it is a lawful—  

Senator ROBERTS: I’ve got no doubt it’s lawful.  

Ms Quinn: And considered by the parliament of the time. Concerns about possible inappropriate practice, as you said, are able to be elevated to the courts.  

Senator ROBERTS: I understand that perfectly. I’ve had it explained before and now again today very well. I understand that it was recommended earlier in a review that the scheme must be overhauled. I want to know the progress of that and when is it going to be done.  

Senator Gallagher: Let me see if there’s—  

Senator ROBERTS: Thank you, Minister. I also make it clear that fraud hurts the taxpayers. I detest it and it must stop. So we’ve got no problems there. I also can see that a doctor who stands up and has got the courage of his or her convictions can go right through that process and won’t buckle. I can see some doctors will buckle because it’s just too much. They’ll let go. So some strong doctors, I believe, are being punished. That’s what I would like to talk to. I don’t want to raise individual cases with you. That’s not my position. I’m not an advocate for individual cases. I just wanted to understand the process better. So I look forward to a conversation.  

Mr Topperwien: We are happy to talk to you in general terms about how the process works, the way that the scheme is structured, the qualifications of the practitioners who are on our panel and who are appointed to committees and how that appointment process works.  

Senator ROBERTS: Thank you.  

CHAIR: Thank you, Senator Roberts. 

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Professional Services Review Scheme Under Question

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The Professional Services Review was created to review misconduct of health professionals in a Medicare context, commonly invoked where there are allegations of over-servicing or Medicare fraud.

This Committee seems to be a law unto itself.

Dr Di Dio confirmed that there is no appeal process from conclusions of the Committee based on Merit. The only appeals available are based on errors of law that would include taking into account evidence that was not relevant or excluding evidence that was relevant. Lawyer Mr Topperwein confirmed that the weight to be placed on evidence was that which the Committee chose to give. He said that the Committee was both the investigator and the judge of the facts with no appeal on merit.

Mr Topperwein could provide no explanation as to why there were no lawyers on the Committee, to ensure the processes were fair and just, stating that the committee comprises practitioner peers.

The concerns about the Review Scheme being a law unto itself seem to be valid, it looks like we need some serious reform in this area.

Transcript

Chair: I welcome the acting director of the Professional Services Review, Dr Antonio Di Dio. Senator Roberts, is it one block of questions here?

Senator ROBERTS: Yes, hopefully we should get through it in one block.

Chair: Dr Di Dio, do you have an opening statement?

Dr Di Dio: No, thank you.

Chair: Alright. Senator Roberts.

Senator ROBERTS: Thank you, Dr Di Dio, for being here again. During the last estimates hearings I asked some questions, and your answers left me confused. Regarding what you gave me, I was feeling somewhat
misled, potentially, because I reviewed it afterwards. I was concerned by a number of submissions made to me about the lack of fairness of the structure by which this review scheme investigates allegations of misconduct by health professionals in a Medicare context. I’ve since done further research into this area and looked over the transcript closely. Just to start with the transcript, the Professional Services Review scheme was set up to review misconduct of health professionals in a Medicare context, commonly invoked where there are allegations of overservicing or Medicare fraud. Isn’t it true that the committee’s conclusions cannot be challenged on merit as to the accuracy or completeness of the basis for the evidence?

Dr Di Dio: The committee’s conclusions are made after an exhaustive and highly respectful process in which the practitioner under review gives evidence and responses in relation to potential concerns about potential
inappropriate practice, whether it is in the billing of Medicare item numbers or whether it is in conduct in association with the billing. The committee process occurs after an earlier process in which the director, firstly,
decides whether a matter will be reviewed; secondly, undertakes a non-compulsory interview with the practitioner involved; and thirdly, decides whether to take no further action under section 91, or a negotiated agreement or a referral to a committee. At each of those steps the practitioner under review is invited to make their submissions, give their evidence and respond to any preliminary concerns, to potentially make those concerns go away with the additional information that comes from the practitioner’s individual responses to each of those preliminary concerns.

So, even before the committee occurs, the practitioner has ample opportunity to respond. But at the committee stage itself, when the practitioner is reviewed by their peers, the practitioner has a great deal of opportunity to respond in as much detail as they wish about those particular concerns.

Senator ROBERTS: Thank you for that long answer. There were a lot of words there—exhaustive evidence and so on. But the fact is that you did not answer my question. My question said: isn’t it true that the committee’s conclusions cannot be challenged on merit—meaning as to the accuracy or completeness of the basis of the conclusions.

Dr Di Dio: Well, the committee is bound by its own obligations to the act—

Senator ROBERTS: Can the doctor challenge the accuracy or completeness of the evidence presented?

Dr Di Dio: Well, the evidence is presented by the doctor in response to those questions. I think perhaps your question is, can the practitioner challenge the evidence that the committee has before it? Is that what you mean?

Senator ROBERTS: Yes.

Dr Di Dio: The committee issues what’s called a notice to produce to the practitioner to ask the practitioner to produce documents, most typically the medical records of the patients who are being reviewed, for whom the particular services may be of concern. So, that evidence comes from the practitioner.

Senator ROBERTS: And I’ll say it again. The committee’s conclusions cannot be challenged on merit.

Dr Di Dio: I’ll refer you to my legal counsel, Mr Topperwien.

Mr Topperwien: It’s quite right that once a committee has gone through the whole process of providing a draft report and then a final report then any challenge to the findings in that final report must be limited to a
question of law, which includes whether they have taken into account irrelevant considerations or have not taken into account relevant considerations and have held a fair hearing. Those are all questions of law. And a challenge can be made to a committee’s findings on the question of law only. There isn’t an appeal to a merits review body.

Senator ROBERTS: Thank you. So, they cannot be challenged on merit, just on the points of law. What weight is placed on the evidence of witnesses called by the doctor under investigation to challenge the case being
made by the committee?

Mr Topperwien: The weight that a committee will give to any evidence depends on the nature of that evidence and how credible it is, and they are matters for the committee to determine.

Dr Di Dio: I would add to that that the practitioner under review is encouraged very much to bring legal representation, and support persons and witnesses are welcome.

Senator ROBERTS: Isn’t it true that the committee takes the role of both prosecutor and decider of facts that make the conclusions and recommendations of the committee?

Mr Topperwien: That is not true. The committee is not a prosecutor. It is an investigatory body. It investigates.

Senator ROBERTS: And once it’s finished its investigation, who does the prosecution of the case?

Mr Topperwien: There is no prosecution of the case.

Senator ROBERTS: Who makes the decision?

Mr Topperwien: There are findings of fact made—whether or not a practitioner engaged in inappropriate practice. And that is the sole duty of the PSR committee—to make a finding as to whether or not the practitioner engaged in inappropriate practice. The consequence of that finding is not a matter for the committee. It is a matter for a separate body called the determining authority.

Senator ROBERTS: I’m of the understanding that the investigation is done by the committee—

Mr Topperwien: Yes.

Senator ROBERTS: and then it decides.

Mr Topperwien: Yes. It decides whether or not the practitioner engaged in inappropriate practice.

Senator ROBERTS: Right. So, it decides. It does the investigation, and then it makes the verdict on its investigation.

Mr Topperwien: Yes.

Senator ROBERTS: So, it’s investigator, policeman—

Mr Topperwien: No—

Senator ROBERTS: It’s also judge.

Mr Topperwien: No. It’s an investigator in that it is charged with looking at whether or not the practitioner engaged in inappropriate practice. Clearly, if that’s its task then it has to investigate and obtain all the evidence
necessary to determine that question which it’s charged with answering.

Senator ROBERTS: So it does an investigation, then it makes the judgement and there can be no appeal or challenge on the merits of the case.

Mr Topperwien: That’s right, because it is an expert body that parliament has given the role of making those sorts of findings.

Senator ROBERTS: We’ll get to that matter of whether it’s expert or not. Isn’t it true that committee members undergo a training course in prosecution and investigation?

Mr Topperwien: They are not given any training in prosecution. They are given some training in relation to how to fulfil their task of investigating in the context of holding hearings when they question the person under review and take evidence.

Dr Di Dio: They are given further training in asking questions respectfully and appropriately.

Senator ROBERTS: Sounds good. Are they provided training in decision-making and natural justice principles.

Mr Topperwien: Yes, they are.

Senator ROBERTS: They are?

Mr Topperwien: Yes.

Senator ROBERTS: Is there any section of the Health Insurance Act 1973 where cross-examination of the committee’s case is prescribed?

Mr Topperwien: The Health Insurance Act does not mention at any point cross-examination.

Senator ROBERTS: How can the strength of the committee’s case be tested without substantial questioning given that the committee determines its own outcomes based on its own prepared case?

Mr Topperwien: At the hearings that the committees hold, the person under review is entitled to question any witnesses. They are able to present whatever evidence they wish to present to the committee.

Senator ROBERTS: Isn’t it true that any appeals from the committee’s decision are limited to procedural issues and merit review is not allowed? I think you’ve already answered that question.

Mr Topperwien: I’ve answered that question.

Senator ROBERTS: Why is there no senior lawyer or judge as part of the committee to ensure fairness of process?

Mr Topperwien: The reality is the committee is made up of the practitioner’s peers. They are all practitioners but at the committee hearing there are always two lawyers from PSR who are very experienced in administrative law, the rules of natural justice, to ensure that the committee hearing is conducted fairly, and the PUR—the person under review—is encouraged to engaged their own lawyer to be with them throughout the whole process.

Senator ROBERTS: I’ll just come to GPs, for example. There is such a wide range of GP services and, if you like, specialties. They’re not specialists—

Mr Topperwien: They are specialists in being general practitioners, yes.

Senator ROBERTS: Okay, but they focus on a particular area, niche, within—

Mr Topperwien: Some do; that’s right.

Senator ROBERTS: And some GPs cannot understand another GP’s work because they haven’t had the experience or the qualifications, particularly the experience.

Mr Topperwien: We try very hard to ensure that the members who are put onto committees have the relevant experience. As closely as we are able to do from the general practitioners who we have on the PSR panel from whom we can choose members to put on committees, we try very hard to ensure that their experience is such that they can well understand the circumstances and context and the type of services that the person under review provides.

Dr Di Dio: To clarify, you’re quite correct: there are general practitioners who have subspecialties, but we try very clearly to match the subspecialties as much as within reason, through the membership of our panel, to those particular practitioners. Most notably a lot of general practitioners do skin work, and we try to match our panel

Senator ROBERTS: Why is there no independent review process, apart from a limited formal appeal process?

Mr Topperwien: The make-up of the PSR COO committees is such that we have the best practitioners in their specialty appointed to the committees and to the PSR panel in order that we have the practitioners most
appropriate and who we have consulted with the relative colleges in their appointment to ensure that the colleges are confident that these practitioners are ones appropriate to assess the conduct of other practitioners.

Senator ROBERTS: So a GP who could be one of the leaders in the country in his or her field could be swamped with work because hardly anyone else is doing it. There wouldn’t be someone who was capable of
understanding that complete picture?

Dr Di Dio: GPs are generally not stupid. GPs are capable of understanding the work of other GPs. Should a GP be practising in a highly specialised area, we do the best that we can to match our panel of expertise with the relevant practitioner. Further, sometimes GPs may be involved in subspecialist activity where, at a stage even earlier than the committee stage, we might get a specialist in that field to review a case in addition to having a GP review the case. We try as hard as we can to match those skills.

Senator ROBERTS: If the committee refuses to give sufficient weight to exculpatory evidence clear on fault or guilt, where does that leave the doctor if they cannot appeal on merit?

Mr Topperwien: The committee hearings are intended to give the practitioner every opportunity to put whatever evidence they want to give to the committee and the COO. The committee then looks at that in detail
and asks probing questions in relation to that evidence. One can’t satisfy everybody that everybody will agree on an outcome. There will always be people who are not happy with whatever outcome there is. But the process is a very fair process. It gets scrutinised by the courts regularly. The courts time and again have upheld how fair the process has been for the person under review.

Senator ROBERTS: I’d like to learn more about that.

Dr Di Dio: Could I add a supplementary answer to that?

CHAIR: You can in a moment. I remind you that there are a lot of senators waiting to move to the next outcome, so if you could be courteous in the promptness of your questions.

Dr Di Dio: I will be brief. After a committee, the practitioner under review has the right to tender further information and evidence should they wish.

Senator ROBERTS: But not appeal the decision.

Dr Di Dio: No, but tender as much further evidence as they wish. Furthermore, there is a draft report issued, to which the practitioner, with their legal representative, of course, can make any response they wish. After that, a final report is issued, to which the practitioner can again make as many submissions as they wish. Over and over the practitioner can provide further evidence and submissions to further parts of the process.

Senator ROBERTS: Wouldn’t it be a better process for a judge to be advised by doctors, as is the case before QCAT, VCAT and a similar structure used in the Medicare Participation Review Committee? Contrary to
previous suggestions, I’d submit that having a judge to chair review proceedings would enhance rather than detract from the fairness of the process.

Mr Topperwien: All I can say is that’s not what the law currently provides. But, from my experience, both as a legal adviser who has assisted with committees and having observed many committee hearings, the process is remarkably fair. The usually three lawyers in the hearing room ensure that it is a fair process.

Senator ROBERTS: My last question. In 2011 there was an inquiry held by the Legal and Constitutional Affairs References Committee into the Professional Services Review scheme. Supplementary comments by
senators Eric Abetz and Bridget McKenzie included that the processes of the Professional Services Review scheme were deficient and led to unjust outcomes. Senator Abetz’s view was that merit review would be a
mandatory requirement for the system to be considered fair and just. This flies in the face of your own view, that merit review is unnecessary. Minister, when will the structure of the Professional Services Review scheme be reconsidered?

Senator McCarthy: I will take that question on notice.

Senator ROBERTS: Thank you.

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