Li Juan (Susan) Xue (00349)
Date of Action: September 8, 2014
Description of Action Taken
In July 2012, the College received an audit inspection report from the Ministry of Health, Audit Investigations Branch concerning the Registrant’s billing practices to the Medical Services Plan (“MSP”). The audit report indicated that 99.7% of a sample of 1,241 claims were inappropriately billed. The Inquiry Committee of the College initiated an investigation and appointed an inspector to review the Registrant’s clinical records at her clinic where she also operated a spa. The inspector reviewed a random sample of clinical records and found that almost all of the treatment records lacked individualized details about the patient and referred only to a generic treatment protocol. The inspector determined that the Registrant billed $220,179 to MSP in 2011, $233,542 in 2012 in addition to $374,193.50 to private insurers in 2012. The youngest of her patients in 2012 was a four month old child who allegedly received 10 acupuncture treatments. When the Registrant refused to provide access to her spa treatments, the College obtained an order for search and seizure under s. 29 of the Act and obtained further records which revealed that in some cases the Registrant was billing MSP for the maximum number of treatments for family constellations.
The Inquiry Committee directed the issuance of a Citation under s. 33(6)(d) of the Health Profession Act (the “Act”) against the Registrant alleging that she contravened the Standards of Practice and Code of Ethics for Registrants and engaged in professional misconduct by: (a) failing to maintain adequate clinical records; (b) billing MSP for acupuncture treatments that were not provided; (c) billing MSP with insufficient evidence to support that acupuncture services were provided to patients for claims submitted to MSP for the period April 1, 2008 to September 30, 2013; and (d) failing to provide an adequate quality of care to individual patients in view of the volume of patients for whom she billed services.
Reasons for Action Taken
The Inquiry Committee directed the issuance of a citation based on concerns that the Registrant had engaged in professional misconduct by misbilling MSP and private insurers for acupuncture treatments that were not provided and failed to cooperate with the College’s investigation.
The Registrant subsequently made an offer under s. 37.1 of the Act to resolve the matter before the commencement of the discipline hearing. Following negotiation, the Inquiry Committee agreed to accept a Consent Order under s. 37.1 because it determined that the terms of the Consent Order reflected the penalties that it would seek if the matter proceeded to a discipline hearing. Under the terms of the settlement, the Registrant admitted that she: (a) failed to maintain adequate clinical records; (b) engaged in professional misconduct by billing MSP for acupuncture treatments that were not provided; (c) engaged in professional misconduct by billing MSP with insufficient evidence to support that the acupuncture services were provided to patients for the claims submitted to MSP for the period April 1, 2008 to September 30, 2013; and (d) engaged in professional misconduct by failing to provide an adequate quality of care to individual patients in view of the volume of patients for whom she billed services.
On September 8, 2014, the Registrant signed a Consent Order under s. 37.1 containing the following terms:
- a reprimand in relation to her professional misconduct;
- cancellation of her registration as a registered acupuncturist without a right to apply for reinstatement for a period of 12 months from the date of the Consent Order;
- an undertaking not to repeat the conduct of improper billing;
- an undertaking not to repeat the conduct of failing to maintain accurate and complete clinical and billing records;
- an undertaking not to repeat the conduct of failing to cooperate with any future College investigations;
- an undertaking to successfully complete a course, at her cost, on professional ethics and clinical recordkeeping, such courses to be approved in advance by the Registrant, and to be successfully completed prior to reinstatement of her registration with the College;
- a requirement to cooperate with random spot audits by an inspector appointed by the College at any time during the two year period following reinstatement and return to practice, to review her clinical records for the purposes of ensuring that she is adhering to proper standards of practice and completing proper clinical and billing documentation. The Registrant acknowledges that the frequency and timing of the audits is at the sole discretion of the Inquiry Committee and that she is responsible for all audit costs; and
- investigative costs in the amount of $10,000.
The Inquiry Committee was satisfied that cancellation of registration with conditions for education and monitoring upon reinstatement would provide specific and general deterrence in respect of improper billing and protect the public.