Responding to Patient Requests for Tests Not Clinically Appropriate
Core Principle
- GPs should only request pathology or diagnostic imaging tests that are:
- clinically indicated
- evidence-based
- necessary for appropriate patient management
- Patient request alone does not justify ordering a test.
- Requests from CAM (complementary and alternative medicine) practitioners do not automatically justify testing.
RACGP Position
RACGP advises GPs to:
- assess the patient clinically first
- explore why the patient wants the test
- determine whether the test is clinically relevant
- decline non-indicated tests
- explain reasoning sensitively
- use shared decision-making
- maintain therapeutic relationship and trust
Patient-centred communication is essential.
Medicare / MBS Rules
MBS “Clinically Relevant” Requirement
Under MBS explanatory note GN.1.2:
Medicare benefits are payable only for clinically relevant services.
A clinically relevant service is one:
generally accepted by the profession as necessary for the appropriate treatment of the patient.
Practical meaning
- GP must independently determine clinical necessity.
- Medicare-funded testing cannot be ordered:
- solely because a patient requests it
- solely because a CAM practitioner recommends it
- solely to help a patient avoid private fees
Examples of Potentially Inappropriate Requests
Common scenarios
- “Hormone panels” without symptoms
- MTHFR testing
- Food intolerance panels
- Hair mineral analysis follow-up tests
- Routine annual blood tests without indication
- Whole body imaging screening
- Vitamin testing without clinical suspicion
- Extensive autoimmune panels without symptoms
Risks of Unnecessary Testing
Patient harms
- overdiagnosis
- incidental findings
- false positives
- unnecessary anxiety
- invasive follow-up procedures
- unnecessary treatment
System harms
- increased healthcare costs
- inappropriate Medicare expenditure
- inefficient resource use
Clinical harms
- cascade investigations
- medicalisation of normal variation
- unnecessary specialist referrals
Medico-Legal Risks
If the GP orders the test:
- the GP becomes responsible for:
- reviewing results
- interpreting results
- follow-up
- acting on abnormalities
- documenting management
This responsibility:
- cannot be delegated to a CAM practitioner
- remains with the requesting GP
Important risk:
- abnormal incidental findings may require further investigation
- failure to follow-up abnormal results can create negligence risk
Services Australia / Audit Risk
If Medicare pays benefits for a non-clinically relevant service:
- Services Australia may:
- investigate
- audit
- request repayment
Potential consequences:
- repayment of benefits
- compliance review
- professional scrutiny
CAM Practitioner Requests
Key issue
Many CAM practitioners:
- cannot order Medicare-funded pathology/imaging
- may advise patients to ask their GP to request tests
GP obligations
- GP must still independently assess clinical relevance
- GP should not act as a “request conduit”
- if clinically unjustified:
- decline Medicare-funded request
- discuss private testing options
Private testing
- patient pays full cost
- requester assumes responsibility for follow-up
Communication Approach
Good communication principles
- acknowledge concerns
- validate patient experience
- explain reasoning clearly
- avoid confrontation
- use shared decision-making
Helpful phrases
- “I understand why you’re asking for this.”
- “My role is to ensure tests are medically appropriate and helpful.”
- “This test is not currently clinically indicated based on your assessment.”
- “Unnecessary tests can sometimes cause harm through false positives and further procedures.”
- “If a practitioner wishes to arrange private testing, that can occur outside Medicare.”
Documentation
Document clearly:
- patient request
- source of request
- symptoms/history/examination
- clinical assessment
- discussion of risks/benefits
- explanation provided
- decision made
- safety-netting/follow-up
Ethical Principles
Beneficence
- act in patient’s best interests
Non-maleficence
- avoid harm from unnecessary testing
Justice
- responsible use of limited healthcare resources
Professional integrity
- maintain evidence-based practice
- avoid inappropriate Medicare billing
Key Takeaway
- Medicare funds clinically relevant tests only.
- The GP must independently justify the test.
- If the GP orders the test, the GP owns the clinical responsibility for the result.
- Patient request alone is insufficient justification for Medicare-funded pathology or imaging.