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