“Detective Sergeant Jim Goble contacted the Board’s Medical Investigator to report the overdose death of Patient A, to whom the licensee has prescribed Gabapentin and Oxycodone, and to request a Board investigation pf the licensee’s prescribing practices. According to the Autopsy Report, dated March 25, 2013, Patient A’s cause of death was accidental acute gabapentin toxicity and the manner of death was accidental.”
COMMONWEALTH OF KENTUCKY
BOARD OF MEDICAL LICENSURE
CASE NO. 1541
IN RE: THE LICENSE TO PRACTICE MEDICINE IN THE COMMONWEALTH OF KENTUCKY HELD BY BAL K. BANSAL, M.D., LICENSE NO. 22004, 700 ST. CHRISTOPHER DRIVE, SUITE 101, ASHLAND, KENTUCKY 41101-7061
AMENDED AGREED ORDER OF INDEFINITE RESTRICTION
Come now the Kentucky Board of Medical Licensure (“the Board”), acting by and through its Inquiry Panel B, and Bal K. Bansal, M.D. (“the licensee”), and, in order to reinstate the licensee’s prescribing privileges, hereby ENTER INTO the following AMENDED AGREED ORDER OF INDEFINITE RESTRICTION:
STIPULATIONS OF FACT
The parties stipulate the following facts, which serve as the factual bases for this Amended Agreed Order of Indefinite Restriction:
1. At all relevant times, Bal K. Bansal, M.D., was licensed by the Board to practice medicine in the Commonwealth of Kentucky.
2. The licensee’s medical specialty is neurology,
3. On or about December 4, 2012, Amanda Ward, R.Ph., Pharmacist Consultant for the Office of Inspector General, Drug Enforcement and Professional Practices Branch of the Cabinet for Health and Family Services (“Drug Enforcement”), discovered a therapeutic duplication of pain medications from two prescribers (including the licensee) and that the licensee was not utilizing KASPER as required by KRS 218A.172. Ms. Ward began an investigation and reviewed a KASPER report containing 195 pages and ranging from July 1, 2012 to March 4, 2013 in regard to the licensee’s prescribing. In the course of her investigation, Ms. Ward found that the licensee’s office was only open to see patients on Wednesdays, Thursdays and Fridays from 2:30pm to 5:30pm; that the licensee had requested only 5 KASPER reports since KRS 218A.172 became effective, despite the high number of Schedule II and Schedule III medications containing hydrocodone that he prescribed; and several patterns of concern, including
Combinations of controlled substance favored by persons who abuse or divert controlled substances;
Patients on multiple medications going to more than one pharmacy;
Long-term use of a controlled substance for which short-term use is generally indicated; and
Prescribing Suboxone without a DATA 2000 waiver
On March 21, 2013, Ms. Ward identified eighteen (18) of the licensee’s patients with prescribing patterns reflective of these concerns and recommended further investigation by the Board.
4. On or about February 19, 2013, Detective Sergeant Jim Goble contacted the Board’s Medical Investigator to report the overdose death of Patient A, to whom the licensee has prescribed Gabapentin and Oxycodone, and to request a Board investigation of the licensee’s prescribing practices. According to the Autopsy Report, dated March 25, 2013, Patient A’s cause of death was accidental acute gabapentin toxicity and the manner of death was accidental.
5. During the course of the Board’s investigation, the Medical Investigator interviewed Janci Murray, R. Ph., who stated substantially as follows: she speaks with the licensee almost daily about patients; during one conversation in April 2012, she told the licensee about her migraine headaches and weight gain and asked him to prescribe her phentermine; and even though she had never been seen by the licensee as a patient, he authorized the prescription to her.
6. When interviewed by the Medical Investigator, the licensee stated that Ms. Murray was not his patient; that Ms. Murray told him that he had authorized the phentermine prescription for her; and that he did not remember authorizing the phentermine prescription for Ms. Murray.
7. In September 2013, a Board consultant reviewed eighteen (18) of licensee’s patient charts and found that the licensee departed from or failed to conform to acceptable and prevailing medical practices. Specifically, the consultant noted
… Dr. Bansal as a neurologist, has been prescribing medications that are above the routine practice of a neurologist, however, I understand that chronic pain management requires patient be managed at a higher doses. Nevertheless, having reviewed the extensive records of individual patients, that I was provided with I am of the opinion the prescription of significantly higher doses of narcotics and other medications with abuse potential has been the practice of Dr. Bansal over a period of past many years, which usually is the practice of a pain management specialist…
… I do think that Dr. Bansal has engaged in conduct, which departs or fails to conform to the standards of acceptable and prevailing medical practice within the Commonwealth of Kentucky. … [O]ver the years since the inception of the Kasper system, HB1 and its requirements Dr. Bansal has not attempted to check the Kasper to verify if the patient that was being prescribed medications under the controlled substance category to see if the patient is getting the medications from him and/or any other physician as well and I understand that he has been doing urine drug screens. Nevertheless, the state requirement of checking Kasper has not been followed up by Dr. Bansal, He should have considered monitoring the patients not only be doing urine drug screen, but also reviewing the Kasper system that was made available and is a requirement by the state.
… Further, there has been no intervention pain specialist evaluation or non-intervention pain specialist evaluation to get a second opinion and no other interventions including physical therapy has been done. I understand that intermittently imaging studies have been done on certain patients. Nevertheless, reevaluation for the need for continued pain management has not been done in the majority of the cases. …
8. On or about October 11, 2013, the licensee submitted a written response to the Board consultant’s report in which he maintained that he did not deviate from acceptable and prevailing medical practices. In regard to patients he evaluates for complaints of pain, the licensee explained that he assesses each patient for the quality, type, location and frequency of their pain; that he performs diagnostic tests and treats patients’ underlying source of pain; and that he utilizes non-narcotic analgesics. He explained that almost all of his patients have tried and failed several difference methods – including physical therapy, TENS unit, column stimulator unit and epidural steroid injections. He explained that he encourages the use of psychotherapy and the continuance of physical and/or any other type of therapy that he patient has had success with in the past. The licensee also stated that, since March 2013, he has implemented procedures to conduct ICASPER evaluations of patients every three months, and more frequently if appropriate.
9. On November 21, 2013, the Board’s Inquiry Panel B reviewed the investigation and the licensee appeared with before and was heard by the Panel before it deliberated. In lieu of the issuance of a Complaint and Emergency Order of Restriction, the Panel and the licensee agreed to enter into an Agreed Order of Indefinite Restriction, which, in part, included terms and conditions restricting the licensee from prescribing controlled substances and requiring that the licensee submit to a physical examination and a neuropsychological evaluation.
10. On or about January 8-10, 2014, the licensee attended and completed the Prescribing Controlled Drugs course at Vanderbilt University Medical Center.
11. On or about January 17, 2014, the licensee confirmed that he read and understood 201 KAR 9:260, Professional Standards for Prescribing and Dispensing Controlled Substances, in its entirety.
12. On or about January 21, 2014, the licensee submitted to a neuropsychological evaluation which disclosed a complex neuropsychological profile which suggests right frontal lobe weakness, perhaps dysfunction, of undetermined ideology. Cognitively, the licensee’s full scale IQ of 90, even with the language problem, was found to be lower than anticipated and may suggest decline. His mental processing speed was “Average” and not pathognomonic for dysfunction. Of concern were “Low Average” performances in perceptual reasoning and working memory; an 18-point difference between the scores in verbal comprehension and perceptual reasoning was deemed to be clinically significant and suggestive of, at least, right hemisphere weakness. The licensee demonstrated relative weakness in his ability to determine essential from nonessential visual data, organize, plan and reason visually; this weakness in nonverbal perception and reasoning is normally associated with the right frontal lobes. The examiner found that although the licensee currently has the cognitive capabilities to practice medicine, he should be evaluated neurologically with imaging studies of the head to rule out a previously undiagnosed or emerging condition.
In March and April 2014, the licensee participated in a Neurology Clinical Evaluation exercises with S. Douglas Deitch, M.D., and L. Creed Pettigrew, M.D., both of whom found the licensee’s scores to be at the highest level. In addition, the licensee submitted to an “intellectual functioning” evaluation with Reed Goldstein, Ph.D., in Philadelphia, Pennsylvania on April 6, who found that the licensee’s current overall level of intellectual functioning falls in the High Average range and is specifically characterized by High Average to Superior verbal and, perceptual reasoning abilities along with Average working memory and processing speed.
13. On or about February 19, 2014, the licensee submitted to a physical examination which did not reveal any obvious medical problems.
14. On or about February 13, the licensee obtained an MRI of the brain (without contrast) which disclosed minimal ethmoid sinus disease but no acute intracranial mass, mass effect, hemorrhage or infarct.
15. On or about February 26, 2014, the licensee prescribed a controlled substance, Tramadol, in a compounded medication to Patient RW, while the licensee was subject to an Agreed Order of Indefinite Restriction pursuant to which he was restricted from prescribing controlled substances.
16. On or about March 7, 2014, the licensee completed the CPEP Documentation Seminar and is currently registered in the post-seminar Post Implementation Program (PIP).
17. On or about May 14, 2014, he attended and completed the University of Kentucky’s College of Medicine’s “Overview of HB I and Regulations.”
18. On May 19, 2014, the licensee reimbursed the Board’s costs of the proceedings in the amount of $750.00.
STIPULATED CONCLUSIONS OF LAW
The parties stipulate the following Conclusions of Law, which serve as the legal bases for this Amended Agreed Order of Indefinite Restriction:
I. The licensee’s Kentucky medical license is subject to regulation and discipline by the Board.
2. Based upon the Stipulations of Fact, the licensee has engaged in conduct which violates the provisions of KRS 311.595(8), (9), as illustrated by KRS 311.597(4), and KRS 311.595(12) and (13). Accordingly, there are legal grounds for the parties to enter into this Amended Agreed Order of Indefinite Restriction.
3. Pursuant to KRS 311.591(6) and 201 KAR 9:082, the parties may fully and finally resolve this pending grievance without an evidentiary hearing by entering into an informal resolution such as this Amended Agreed Order of Indefinite Restriction.
AMENDED AGREED ORDER OF INDEFINITE RESTRICTION
Based upon the foregoing Stipulations of Fact and Stipulated Conclusions of Law, and, in order to reinstate the licensee’s prescribing privileges, the parties hereby ENTER INTO the following AMENDED AGREED ORDER OF INDEFINITE RESTRICTION (“Order”):
1. The license to practice medicine in the Commonwealth of Kentucky held by Bal K. Bansal, M.D., is RESTRICTED/LIMITED FOR AN INDEFINITE PERIOD OF TIME, effective immediately upon the filing of this Order.
2. During the effective period of this Order, the licensee’s Kentucky medical license SHALL BE SUBJECT TO THE FOLLOWING TERMS AND CONDITIONS OF RESTRICTION/LIMITATION for an indefinite term, or until further order of the Board:
a. The licensee fully comply with the provisions of 201 KAR 9:260, Professional Standards for Prescribing or Dispensing Controlled Substances and the professional standards applicable to the licensee’s specialty;
b. The licensee SHALL maintain a “controlled substances log” for all controlled substances prescribed. The controlled substances log SHALL include date, patient name, patient complaint, medication prescribed, when it was last prescribed and how much on the last visit. Note: All log sheets will be consecutively numbered, legible i.e. printed or typed, and must reflect “call-in” and refill information. Prescriptions should be maintained in the following manner: 1) patient; 2) chart; and 3) log;
c. The licensee SHALL permit the Board’s agents to inspect, copy and/or obtain the controlled substance log and other relevant records, upon request, for review by the Board’s agents and/or consultants;
d. The licensee SHALL reimburse the Board fully for the costs of each consultant review performed pursuant to this Order. Once the Board receives the invoice from the consultant(s) for each review, it will provide the licensee with a redacted copy of that invoice, omitting the consultant’s identifying information. The licensee SHALL pay the costs noted on the invoice within thirty (30) days of the date on the Board’s written notice. The licensee’s failure to fully reimburse the Board within that time frame SHALL constitute a violation of this Order;
e. The licensee understands and agrees that at least two (2) favorable consultant reviews must be performed, on terms determined by the Panel or its staff, before the Panel will consider a request to terminate this Order;
f. The licensee SHALL successfully complete the CPEP Personalized Implementation Program (PIP), at his expense, without delay, and as directed by CPEP;
i. The licensee SHALL provide the Board’s staff with written verification that he has successfully completed PIP promptly after completing that program; and
ii. The licensee SHALL take all steps necessary, including signing any waiver and/or consent forms required to ensure that CPEP will provide a copy of any evaluations from the PIP to the Board’s Legal Department promptly after their completion;
g. Pursuant to KRS 311.565(1)(v), the licensee SHALL submit payment of a FINE to the Board in the amount of five-thousand dollars ($5,000.00) within six (6) months from the date of entry of this Order; and
h. The licensee SHALL NOT violate any provision of KRS 311.595 and/or 311.597.
3. The licensee expressly understands and agrees that if he should violate any term or condition of this Order, the licensee’s practice will constitute an immediate danger to the public health, safety, or welfare, as provided in KRS 311.592 and 13B.125. The parties further agree that if the Board should receive information that he has violated any term or condition of this Order, the Panel Chair is
authorized by law to enter an Emergency Order of Suspension or Restaction immediately upon a finding of probable cause that a violation has occurred, after an ex parte presentation of the relevant facts by the Board’s General Counsel or Assistant General Counsel. If the Panel Chair should issue such an Emergency Order, the parties agree and stipulate that a violation of any term or condition of this Order would render the licensees practice an immediate danger to the health, welfare and safety of patients and the general public, pursuant to KRS 311.592 and 1313,125; accordingly, the only relevant question for any emergency hearing conducted pursuant to KRS 1313,125 would be whether the licensee violated a term or condition of this Order,
4. The licensee expressly understands and agrees that any violation of the tents of this Order would provide a legal basis for additional disciplinary action, including revocation, pursuant to KRS 311.595(13), and may provide a legal basis for criminal prosecution.
SO AGREED on this 17 December 2013
FOR THE LICENSEE:
BAL K. BANSAL, MD.
COUNSEL FOR LICENSEE
FOR THE BOARD
RAND C. GIBSON, D.O.
CHAIR, INQUIRY PANEL B
LEANNE K. DIAKOV
General General Counsel
Kentucky Board of Medical Licensure
310 Whittington Parkway, Suite 1B
Louisville, Kentucky 40222
Tel. (502) 429-7150