What is 'inappropriate practice'?

Inappropriate practice is conduct by a practitioner in connection with rendering or initiating services that a practitioner’s peers could reasonably conclude was unacceptable to the general body of their profession.

The key elements of this definition are:

  • whether a practitioner's practice/conduct when providing or initiating Medicare services would be unacceptable to the general body of their peers
  • whether a practitioners conduct in prescribing or dispensing PBS medicines would be unacceptable to the general body of their peers.

Relevant considerations used to determine whether inappropriate practice occurred are:

  • whether the service a practitioner provided met the requirements of the MBS or PBS item descriptor. This includes whether services were medically necessary and clinically relevant
  • whether the circumstances in which services were rendered constitute a ‘prescribed pattern of services'. (The legislation provides that a 'prescribed pattern of services' exists if a general practitioner rendered 80 or more professional attendance services on 20 or more days during a 12 month period.) 
  • whether there were exceptional circumstances affecting the rendering of professional attendances on each or any of the days included in a prescribed pattern of services
  • whether or not a practitioner kept adequate and contemporaneous records for Medicare or PBS services they have rendered or initiated. The Health Insurance (Professional Services Review) Regulations 1999 requires:
    • the record to clearly identify the name of the patient
    • the record to contain a separate entry for each attendance by the patient for a service
    • the date on which the service was rendered or initiated
    • each entry to provide clinical information adequate to explain the type of service rendered or initiated
    • each entry to be sufficiently comprehensible so that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care
    • that the record be completed at the time the practitioner rendered or initiated the service or as soon as practicable after the service was rendered or initiated by the practitioner