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Billing, Kulbir Singh

CPSO#: 33075

MEMBER STATUS
Expired: Resigned from membership as of 25 May 2019
CURRENT OR PAST CPSO REGISTRATION CLASS
None as of 07 Aug 2018

Summary

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Former Name: No Former Name

Gender: Male

Languages Spoken: English, Hindi, Panjabi/Punjabi

Education: Bhopal University, 1975

Practice Information

Primary Location of Practice
Practice Address Not Available

Professional Corporation Information


Corporation Name: Kulbir S. Billing Medicine Professional Corporation
Certificate of Authorization Status: Inactive: Aug 15 2019
 

Medical Records Location

Instructions/Address:

To access medical records patients or their representatives may contact: Record Storage and Retrieval Services 111 St Regis Crescent South, North York, Ontario, M3J 1Y6. Tel: 416-398-0638 Fax: 416-342-1052
Date Received: 14 Nov 2019

Hospital Privileges

No Privileges reported.


Hospital Notices

Source:  Hospital
Active Date:  April 1, 2014
Expiry Date:  
Summary:  
On April 4, 2014, Guelph General Hospital notified the College that Dr. K.S. Billing's privileges were suspended on a temporary basis, effective April 1, 2014.

Specialties

Specialty Issued On Type
Anesthesiology Effective:20 Nov 1984 RCPSC Specialist

Registration History

Action Issue Date
First certificate of registration issued: Postgraduate Education Certificate Effective: 02 Jul 1980
Transfer of class of registration to: Independent Practice Certificate Effective: 02 Feb 1982
Transfer of class of certificate to: Restricted certificate Effective: 22 Jun 2017
Terms and conditions imposed on certificate Effective: 22 Jun 2017
Transfer of class of registration to: Independent Practice Certificate Effective: 30 Jun 2017
Suspension of registration imposed: Discipline Committee Effective: 16 May 2018
Suspension of registration removed Effective: 16 Jul 2018
Transfer of class of certificate to: Restricted certificate Effective: 07 Aug 2018
Terms and conditions imposed on certificate Effective: 07 Aug 2018
Expired: Resigned from membership. Expiry: 25 May 2019

Previous Hearings

Committee: Discipline
Decision Date: 21 Nov 2016
Summary:

On November 21, 2016, the Discipline Committee of the College of Physicians and Surgeons of Ontario found that Dr. Kulbir Singh Billing committed an act of professional misconduct in that he failed to maintain the standard of practice of the profession.

Dr. Billing, an anaesthesiologist in Kitchener, has a practice primarily devoted to injection therapies for chronic pain, including nerve blocks, paravertebral blocks, epidural injections, and trigger point injections.

After receiving information from the Ministry of Health and Long-Term Care in 2011, the College commenced an investigation into Dr. Billing’s clinical practice pursuant to s.75(1)(a) of the Health Professions Procedural Code.

As part of its investigation, the College obtained independent opinions from two experts, who reviewed dozens of patient charts and observed Dr. Billing’s care of certain patients. Dr. Billing obtained independent opinions from two other experts, who reviewed the same patient charts and observed Dr. Billing’s care of patients.

Dr. Billing’s documentation in his patient charts had the following deficiencies:
- Initial patient histories are not always present. When present, the patients’ histories often lack, or record an incomplete, past medical and medication history;
- Previous treatments for chronic pain are not always well-documented;
- The effect or efficacy of blocks administered to patients is not always well-documented;
- When recorded, changes in treatment plans or injection therapies are not explained in the chart;
- Changes in patients’ diagnoses do not always reflect a change in treatment plans and no explanation is provided;
- The correlation between physical diagnoses or findings and the treatment provided is often not documented;
- Dr. Billing uses template-style reporting, or note-stamping, i.e. he “cuts and pastes” from patients’ previous clinical notes, carrying over grammatical and spelling errors;
- Although Dr. Billing documents a review of the complications that may arise from nerve blocks in general, he does not document a discussion of the specific and unique complications that may arise when obtaining consent to a new kind of nerve block;
- Patient consent to procedures is often poorly documented; and
- There is often a failure to document changes, or lack of changes, in functionality or activities of daily living of patients.

Between 2006 and 2013, Dr. Billing submitted claims to OHIP for the maximum number of nerve blocks allowed under the Schedule of Benefits, namely eight blocks per patient per service date for many of his patients. From April 2010 to March 2014, Dr. Billing submitted claims to OHIP for an average of 10 to 11 injections per patient per service day.

Dr. Billing’s evidence of individualized treatment plans had the following deficiencies:
- The records do not always indicate an attempt to create individualized treatment plans;
- Many patients receive more blocks than the maximum eight paid by OHIP. The rationale for providing patients with the maximum or greater than the maximum number of blocks is not always sufficiently documented;
- Many patients are given the same or similar sets of nerve blocks and trigger point injections without a documented rationale;
- Although Dr. Billing uses patient feedback to determine which blocks work best, this feedback approach is not always clearly reflected in his clinical notes;
- It is difficult to determine the effect or benefit of any particular block, given Dr. Billing’s practice of routinely initiating multiple blocks simultaneously and his failure to record patients’ responses to various blocks;
- In several instances, Dr. Billing did not adjust his treatment based on new evidence when new findings or diagnostic results, such as imaging became available, and/or he failed to record any adjustments to treatment based on new findings or diagnostic results; and
- When a patient notes a new area of pain, Dr. Billing often performs nerve blocks without documenting investigations to confirm the diagnosis.

Due to their proximity to the epidural space, paravertebral blocks (a block of the spinal nerve where local anesthetic is injected in the paravertebral space) must be done using appropriate sterile technique due to the rare, but potentially severe consequences of infection in this area, including epidural abscess and paralysis.

“Sterile technique” means that everything used in the injection must be sterile, including the target area on the patient’s skin for the injection, which must be cleaned in a sterile fashion; the syringe, the needle, and the solution in the syringe; and the gloves, which must also be sterile.

Dr. Billing’s technique in administering paravertebral blocks had the following deficiencies with respect to the sterile technique used:
- He only used only alcohol swabs to sterilize the general block area, not the stronger chlorhexidine spray. According to Dr. Billing, he began to use chlorhexidine spray when this issue was drawn to his attention by an expert;
- He administered injections to individual patients using the same needle that had already been used to perform occipital nerve blocks through the patients’ scalps. The scalp area is notoriously difficult to sterilize;
- He did not appropriately maintain the sterility of his gloves, in that although he started with sterile gloves, while he was administering injections, he used gloves that had touched unsterilized areas of the patients, including their scalps.

PENALTY

On January 17, 2017, the Discipline Committee reserved its decision on penalty. On June 22, 2017, the Discipline Committee released its decision on penalty and ordered that:

- The Registrar suspend Dr. Billing’s Certificate of Registration for a two (2) month period effective thirty (30) days from the date of this Order.
- The Registrar impose the following terms, conditions and limitations on Dr. Billing’s certificate of registration:
1. Clinical Supervision
(a) Within twenty (20) days of this Order, Dr. Billing shall retain a College-approved Clinical Supervisor or supervisors (the “Clinical Supervisor”) with respect to his chronic pain management practice, who will sign an undertaking in the form attached hereto as Schedule “A”.
(b) For a period of twelve (12) months commencing on the date that the Clinical Supervision is approved by the College, Dr. Billing may practise chronic pain management only under the supervision of the Clinical Supervisor (“Clinical Supervision”). Clinical Supervision of Dr. Billing’s practice will end after a period of twelve (12) months.
(c) Clinical Supervision of Dr. Billing’s chronic pain management practice shall contain the following elements:
Moderate-Level Supervision
(a) For an initial period of four (4) months, the Clinical Supervisor will engage in a period of moderate-level supervision, during which time the Clinical Supervisor will meet with Dr. Billing every two weeks and will at minimum:
i. review a minimum of fifteen (15) of Dr. Billing’s patient records, to be selected at the sole discretion of the Clinical Supervisor, and discuss any issues or concerns arising therefrom with Dr. Billing;
ii. directly observe Dr. Billing’s treatment of patients, including patient consultations and his administration of injections, for a minimum of three (3) hours per visit;
iii. discuss with Dr. Billing any concerns the Clinical Supervisor may have arising from the chart reviews or the direct observations;
iv. make recommendations to Dr. Billing for practice improvements and ongoing professional development, and inquire into Dr. Billing’s compliance with the recommendations; and
v. keep a log of all patient charts reviewed along with patient identifiers.
(b) The Clinical Supervisor shall consider the need for moderate supervision after the first four (4) months of Dr. Billing’s Clinical Supervision, and at the beginning of every month thereafter for as long as the period of moderate supervision continues. If the Clinical Supervisor believes that Dr. Billing is ready to practise under low supervision, he/she shall provide the College with a report addressing the practice concerns raised in the Statement of Uncontested Facts on Liability.
(c) The College must agree to the transition to the next phase, based on the reports of the Clinical Supervisor.
Low-Level Supervision
(a) If the transition is approved by the College, for a period of a further eight (8) months, the Clinical Supervisor will engage in a period of low-level supervision, during which time the Clinical Supervisor will meet with Dr. Billing on a monthly basis and will:
i. review a minimum of ten (10) of Dr. Billing’s patient records, to be selected at the sole discretion of the Clinical Supervisor, and discuss any issues or concerns arising therefrom with Dr. Billing;
ii. directly observe Dr. Billing’s treatment of patients, including his patient consultations and his administration of injections, for a minimum of three (3) hours per visit;
iii. discuss any concerns the Clinical Supervisor may have arising from the chart reviews or the direct observations;
iv. make recommendations to Dr. Billing for practice improvements and ongoing professional development and inquire into Dr. Billing’s compliance with the recommendations; and
v. keep a log of all patient charts reviewed along with patient identifiers.
Other Elements of Clinical Supervision
(a) Throughout the period of Clinical Supervision, Dr. Billing shall abide by all recommendations of his Clinical Supervisor with respect to his practice, including but not limited to patient care, record keeping, infection control, practice improvements, and ongoing professional development.
(b) The Clinical Supervisor shall submit written reports to the College at least once every month, or more frequently if the Clinical Supervisor has concerns about Dr. Billing’s standard of practice.
(c) If the person who has given an undertaking in Schedule “A” to this Order is unable or unwilling to continue to fulfill its provisions, Dr. Billing shall, within twenty (20) days of receiving notice of same, obtain an executed undertaking in the same form from a similarly qualified person who is acceptable to the College and ensure that it is delivered to the College within that time.
(d) If Dr. Billing is unable to obtain a Clinical Supervisor as set out in this Order, he will cease practising medicine until such time as he has obtained a Clinical Supervisor acceptable to the College.
(e) If Dr. Billing is required to cease practise as a result of section (5)(d) above, this will constitute a term, condition or limitation on his certificate of registration and that term, condition or limitation will be included on the public register.

2. Re-Assessment of Practice
(a) Approximately three (3) months after the completion of Clinical Supervision, Dr. Billing shall undergo a reassessment of his chronic pain management practice by a College-appointed assessor (the “Assessor”). The assessment shall include a review of Dr. Billing’s patient charts and direct observation of patient care. The assessment may also include interviews with staff and/or patients. The results of the assessment shall be reported to the College.
(b) Dr. Billing shall consent to sharing of information among the Assessor, the Clinical Supervisor, and the College, as any of them deem necessary or desirable in order to fulfill their respective obligations.

3. Monitoring
(a) Dr. Billing shall inform the College of each and every location where he practises, in any jurisdiction (his “Practice Location(s)”) within fifteen (15) days of this Order and shall inform the College of any and all new Practice Locations within fifteen (15) days of commencing practice at that location.
(b) Dr. Billing shall cooperate with unannounced inspections of his chronic pain management practice and patient charts by a College representative(s) for the purpose of monitoring and enforcing his compliance with the terms of this Order.
(c) Dr. Billing shall consent to the College’s making appropriate enquiries of the Ontario Health Insurance Plan and/or any person or institution that may have relevant information, in order for the College to monitor and enforce his compliance with the terms of this Order.
(d) Dr. Billing shall be responsible for any and all costs associated with implementing the terms of this Order.
- Dr. Billing appear before the panel to be reprimanded within 30 days of the date this Order becomes final.
- Dr. Billing pay costs to the College for a one (1) day hearing in the amount of $5,000 within 30 days of the date of this Order becomes final.

APPEAL

On June 30, 2017, Dr. Billing appealed the penalty decision of the Discipline Committee to the Superior Court of Justice (Divisional Court). Pursuant to s. 25(1) of the Statutory Powers Procedure Act, the appeal operated as a stay of the decision pending the outcome of the appeal.
On April 25, 2018, the Divisional Court dismissed Dr. Billing’s appeal. Therefore, the decision of the Discipline Committee is in effect. The parties agreed that the suspension shall commence within 21 days of the date of the Court’s order.
 


Decision: Download Full Decision (PDF)
Hearing Date(s): Hearing: November 21, 2016, January 16-17, 2017

Concerns

Source: Member
Active Date: May 25, 2019
Expiry Date:
Summary:
Summary of the Undertaking given by Dr. Kulbir Singh Billing to the College of Physicians and Surgeons of Ontario, effective May 25, 2019:

Following a public complaint, a College investigation was conducted into Dr. Billing’s interventional pain management practice and his infection prevention and control. During the investigation, Dr. Billing resigned from the College and has agreed never to apply or reapply for registration as a physician in Ontario.
Download Full Document (PDF)