Inappropriate practice

Conduct unacceptable to peers

Inappropriate practice is conduct that a practitioner’s peers could reasonably conclude is unacceptable to the general body of their profession or specialty. It includes a practitioner’s conduct related to:

• providing Medicare or CDBS service
• prescribing or supplying PBS medicines.

To determine if inappropriate practice might have occurred, the Director considers:

• if the service met the requirements of the Medicare or PBS item descriptor, including whether it was medically necessary and clinically relevant
• if the service circumstances form a ‘prescribed pattern of services’ (defined as providing 80 or more relevant services or 30 or more relevant phone services on 20 or more days over 12 months)
• whether exceptional circumstances affected the delivery of these services on any of the days included in the prescribed pattern of services
• whether a practitioner kept adequate and contemporaneous records for the Medicare, PBS or CDBS services they provided.

Medical records must include certain details as described in the Health Insurance (Professional Services Review Scheme) Regulations 2019. They must:

• clearly identify the patient’s name
• contain a separate entry for each time the patient attends for a service
• be able to be understood by another practitioner so they can provide ongoing care of the patient.

The separate entries in each record must:

• include the date of each service
• provide enough clinical information to explain the type of service provided
• be completed at the time the service was provided or as soon as practicable afterwards.
   

Education, information and tools

The PSR Scheme is just one way that the Department of Health and Aged Care manages Medicare compliance by health practitioners.

The Department also helps practitioners by providing education and information to ensure that that they provide services appropriately and claim Medicare and PBS benefits correctly.

Tools available to support practitioners include:

• eLearning products
• quick reference guides
• handbooks and other resources
• provider enquiry line.

For further information, please visit the Department of Health and Aged Care’s Medicare Compliance webpage.