Psychiatrist ordered to repay $100,000 in Medicare billings after records found inadequate

Doctors who claim for services under the Medicare Benefits Schedule (MBS) must keep adequate and contemporaneous records. The records need to show the doctor provided a service that satisfies all the elements of each item number. Inadequate records can result in orders to repay benefits in full and bans on billing certain item numbers in future. 

Medicare records

Dr B, a psychiatrist, was referred to a Professional Services Review (PSR) Committee over their billing of consultations in their rooms and home visits (MBS items 300, 302, 304, 330 and 332).

Following an audit, the committee determined that in almost all cases the psychiatrist’s records were so inadequate as to constitute inappropriate practice.

In many of the cases reviewed there were no records of the consultations. Patients appeared to have been seen regularly for extended periods without Dr B documenting any notes.

While in most cases notes had been kept for home visits, these did not contain enough information to allow another practitioner to take over care of the patient.

For item numbers involving a time component, it was not possible to understand how long the consultation had taken, or why a longer consultation was needed.

Records of prescribing

The committee was also concerned that the medical records did not support Dr B’s prescribing. It was particularly concerned about Dr B’s prescribing of antipsychotics and benzodiazepines, which were at higher than expected rates.

While acknowledging that Dr B was providing important home-based care to a disadvantaged community, Dr B’s inappropriate practice was sufficiently concerning to justify penalties.

Dr B was reprimanded.

Dr B was ordered to repay MBS benefits of $100,000 and disqualified for 12 months for billing in-room item numbers (300, 302 and 304).

When you make a Medicare claim for a service, the law requires you to maintain an adequate and contemporaneous medical record that demonstrates the service was provided. If your records are found to be inadequate, you may be required to repay the Medicare benefits paid for the service in full.

For Medicare, your records need to identify the patient and include a separate entry for each attendance by the patient for a service.

Be sure your consultation with the patient covers all required elements for the item numbers you have charged.

Make sure you document enough detail that someone reading the records could understand why the service was needed, the clinical input you provided, and why the particular item number was billed. Where the item number involves a time component, you need to document the time taken for the consultation and enough detail to explain why a longer consultation was needed.

Your medical records – for Medicare purposes and otherwise – need to be clear and up-to-date. Always include enough detail so another practitioner could take over the patient’s care if needed.

Avant resources – Medicare: what you need to know

Department of Health - AskMBS Email Advice Service

Avant factsheet – Medical records: the essentials