Billing, Kulbir Singh (CPSO#: 33075)

Current Status: Active Member as of 02 Jul 1980

CPSO Registration Class: Independent Practice as of 30 Jun 2017

Indicates a concern or additional information

Summary

Former Name: No Former Name

Gender: Male

Languages Spoken: English, Hindi, Panjabi/Punjabi

Education:Bhopal University, 1975

Practice Information

Primary Location of Practice
Unit 30B
1601 River Road East
Kitchener ON  N2A 3Y4
Phone: (519) 745-6505
Fax: (519) 745-6506
Electoral District: 03
View Professional Corporation Information

Professional Corporation Information

Corporation Name: Kulbir S. Billing Medicine Professional Corporation

Certificate of Authorization Status: Issued Date:  Nov 05 2003

Shareholders:
Dr. K. Billing ( CPSO# 33075 )

Business Address:
Unit 30B
1601 River Road East
Kitchener ON  N2A 3Y4
Phone Number: (519) 745-6505

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

Terms and Conditions

Details

(1) Dr. KULBIR SINGH BILLING may practise only in the areas of medicine in which Dr. BILLING is educated and experienced.

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

Previous Discipline 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 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 operates as a stay of the decision pending the outcome of the appeal. Therefore, the 
decision of the Discipline Committee is not in effect.

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