Responding to patient requests for tests not considered clinically appropriate

Position

To prevent harm to patients, meet professional obligations, reduce medico-legal risk, and ensure appropriate use of the Medicare Benefits Schedule (MBS), GPs should only request medical imaging and pathology tests that are clinically indicated.

Background

GPs occasionally receive requests from patients to request specific medical imaging or pathology tests that may or may not be appropriate in the management of the patient. Test requests arise from a variety of sources. Complementary and alternative medicine (CAM) practitioners might advise patients that they can avoid paying for specific tests if they ask a GP to request them through Medicare.¹ Requests also occur when patients research their symptoms and present at the clinic with a proposed course of action.

GPs may experience pressure to comply with these requests in order to preserve good relations with their patients. They may also be concerned about medico-legal liability that might stem from delayed diagnosis. However, there are various risks associated with requesting tests that are unlikely to be of clinical benefit.

Therapeutic risks

The patient’s wellbeing must be the primary consideration in determining whether to request particular tests. Testing can be painful and anxiety-provoking, and can lead to unnecessary, expensive, and potentially dangerous treatment. Insurance companies may apply loadings or exclusions in light of particular test results.

Medico-legal risks

Billing services to Medicare

In determining whether to bill a particular service to Medicare, GPs must consider whether there is clinical justification to do so. Section G.1.2 of the MBS states that benefits can only be claimed for services that are ‘clinically relevant’.² To meet this standard, the service being rendered must be accepted by the relevant health profession as necessary for the appropriate treatment of the patient. Fee and payment arrangements for tests that are not considered clinically relevant are a matter for discussion between practitioner and patient. In situations where a GP requests a test under the MBS that is later deemed inappropriate, the GP will be obliged to repay the Medicare benefit to the Department of Human Services.²

Professional responsibility

Irrespective of billing arrangements, requesting tests at the request of a patient may expose GPs to medico-legal risk. GPs have a responsibility to review and act upon the results of any test they request. This responsibility cannot be delegated to a CAM or other practitioner.³ It is therefore important for GPs to consider whether they are familiar with the tests they are planning to request and are able to interpret the results.

Responding to requests

GPs can use various strategies for dealing with test requests and can adapt their response to suit individual patients.⁴ Negotiating situations such as these is a defining aspect of doctors’ work.

A prudent approach would be to first assess the patient’s presenting concern, determine whether there is a need for particular tests, and request these tests through the Medicare system. GPs are advised to decline request for tests that are not clinically relevant.

GPs should bear in mind that patients who have sought answers from complementary and alternative approaches might have done so because they have not received benefit from conventional medical assessment and treatment. When denying test requests, it is important for GPs to explain their reasoning to patients in a sensitive manner.

Patients who have requested tests on behalf of a CAM practitioner can be advised that this person may be able to request the tests outside of the Medicare system (eg, directly from a pathology service). In this situation, patients will incur the full cost of testing.

To assist GPs to explain these issues, the RACGP has developed a patient information sheet and template letter to CAM practitioners.

Related resources

Patient information on appropriate diagnostic testing (PDF 477 KB)

Letter to CAM practitioners regarding appropriate diagnostic testing (DOC 27 KB)

RACGP Position Statement: Non-GP initiated testing (PDF 673 KB)

RACGP Position Statement: Independent non-medical practitioner prescribing (PDF 121 KB)

RACGP Position Statement: Homeopathy (PDF 151 KB)

NPS MedicineWise: Choosing Wisely Australia

First do no harm: a guide to choosing wisely in general practice