Medicare FAQs

Services Australia and the Department of Health, Disability and Ageing have a range of educational material for health professionals about Medicare available at: 

• Services Australia: Medicare Benefits Schedule – Medicare Basics for new Health Professionals 
• Services Australia: Medicare Benefits Schedule 
• Services Australia: Starting with Medicare as a health professional 
• Services Australia: Health Professional Education Resources 
• Services Australia: Professional recognition information 
• Services Australia: eLearning – Medicare billing and claiming basics 
• Australian Government – Department of Health, Disability and Ageing: Understanding Medicare: Provider Handbook  

In summary, to be eligible for payment of a Medicare benefit the service: 

• is required to be ‘clinically relevant’ and medically necessary.  Generally, this means the service is accepted by your peers as being necessary for the appropriate treatment of the patient; and 
• must be rendered while both you and the patient are in Australia (section 10 Health Insurance Act). 

It is also important to remember that a practitioner is personally responsible for all item numbers that are billed under their provider number.  Work with your practice manager to set up a system to always review items that have been billed under your provider number and ensure you understand the full item descriptor and the explanatory notes that are relevant to each item you are billing. 

Regularly review MBS Online (MBS Online - MBS Online) to ensure you stay up to date with the requirements.  Use the knowledge of more experienced peers to advise you on best practice.  However, do not rely on ‘corridor advice’ or hearsay from colleagues as a substitute for your own knowledge and understanding.  If you are unsure about any aspect of billing for Medicare services, seek clarification from the Department of Health, Disability and Ageing askMBS@health.gov.au or discuss with Avant. 

When you make a Medicare claim for a service (bulk-billed or otherwise), it is a legal requirement that you maintain an adequate and contemporaneous medical record of the service.  To be adequate, the record needs to:

• clearly identify the name of the patient
• contain a separate entry for each attendance by your patient for a service and the date the service was rendered or initiated
• provide clinical information adequate to explain the type of service rendered or initiated at each attendance
• contain sufficient information to support that the requirements for the Medicare item number have been met
• be sufficiently comprehensible so that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care.

To be contemporaneous the record must be completed at the time the service was rendered or initiated or as soon as practicable afterwards.

If you use macros or templates, review these regularly to ensure information that is automatically recorded is appropriate for the particular patient and the treatment which was provided to them.  Specifically, you need to remove any information from the automatically recorded template if it does not apply to your patient.  If it is inadvertently left in the medical record it may be argued that the entry was automatically generated and that the other elements of the attendance were not met.  Be vigilant in reviewing entries for auto-fill templates because they are commonly criticised by Medicare regulators.

If you use an AI scribe to draft your clinical record, you must ensure that you have reviewed and corrected the output before you enter it into the final medical record, and always make sure the correct MBS item number is used for billing. Remember you are ultimately responsible for the accuracy of your clinical records. If an item number is suggested by an AI tool, you must ensure that you meet the item requirements before billing.  It will not be satisfactory to suggest that the item number was suggested by an AI tool.  Further information can be found in our factsheet: Artificial Intelligence for medical documentation.  

The level of documentation required by Medicare is the same as your obligations under the Medical Board’s Good medical practice: a code of conduct, (10.5) which says another doctor should be able to tell what went on in the consultation when they read your notes.

Your medical records are not just a reminder for you.  Medical records are a scientific record of the patient’s care and a billing record that is legally mandated.  Good records will also provide you with the best chance of a good outcome if you are reviewed or audited.

It is important that the clinical record reflects what occurred during a consultation and provides evidence that the claimed item number was appropriate.  The record is expected to contain information such as history, investigation, a management plan and/or preventative health care to a sufficient degree that makes it clear the consultation would have taken the duration that is required for any time-based Medicare item numbers.  For example, a simple “script written” with no other detail would not generally be enough to establish that a consultation took six minutes. 

If you feel that an MBS item number is outdated you should make an enquiry with askMBS (MBS Online - AskMBS Email Advice Service) and request a written response in relation to the current requirements for the item number.

You are required to store medical records for Medicare purposes for two years.  However, our general recommendations are to store the record for longer than this. More information can be found in our Storing, retaining and disposing of medical records factsheet.

Links:

Australian Government – Department of Health, Disability and Ageing: Administrative record keeping guidelines for health professionals

If you are undertaking a locum placement at a particular location for two weeks or more, or if you intend to do a recurring locum placement at the same location for less than two weeks on a regular basis, you should apply for a provider number for that location.

If you are undertaking a locum placement for less than two weeks at the location and do not anticipate returning to the location, you should contact Services Australia to check if you should obtain a provider number for the locum tenens placement not specific to the location. 

If you are relieving a specialist but do not hold specialist registration you cannot claim Medicare benefits at a specialist rate.  You should refer to MBS Online to review the explanatory memorandum that applies to your circumstances.

Links:

Australian Government – Department of Health, Disability and Ageing: Medicare Benefits Schedule – Note GN.2.6 Locum tenens

Australian Government – Department of Health, Disability and Ageing: Medicare Benefits Schedule – Note GN.6.16 Referral of Patients to Specialists or Consultant Physicians

No. Your provider number can only be used for services you provide. Locums will need to obtain their own provider number.

You can have a non-GP specialist consultation with a patient without a referral.  However, without a valid referral you won’t be able to access Medicare benefits for that consultation. 

The patient’s treating health practitioner should have a consultation with the patient to establish the need for the non-GP specialist’s involvement before the non-GP specialist is engaged.

A GP cannot backdate a referral after the patient has been seen.  Back dating a referral is fraud.  The Health Insurance Act makes it an offence to offer a false statement relating to Medicare benefits. 

If a referral was made but has been lost, stolen or destroyed, the specialist can note “lost referral” for the initial attendance and Medicare benefits can be claimed.  However, a replacement referral or letter will be required to claim Medicare benefits for any subsequent attendances with the specialist.  Similarly, the word ‘emergency’ must be included on the claim where that is relevant.  In either case, only one consultation without a written referral can be rendered before a formal referral is obtained.

Changes to the Chronic Disease Management Framework come into effect from 1 July 2025.  Further information regarding this framework will be available after this date. 

MBS Online states that an after-hours consultation is ‘urgent’ if the medical practitioner first determines that the patient requires urgent medical assessment.  It states that when considering the need for an urgent assessment of a patient’s condition, the practitioner may rely on information conveyed by the patient or patient’s carer, other health professionals or emergency services personnel.  A record of the assessment must be completed and included in the patient’s medical record.

The MBS urgent after-hours items may be used when, on the information available to the medical practitioner, the patient’s condition requires urgent medical assessment during the after-hours period to prevent deterioration or potential deterioration in their health.  Specifically, the patient’s assessment:

• cannot be delayed until the next in-hours period; and
• the medical practitioner must attend the patient at the patient’s location or reopen the practice rooms. 

It is important to document the reasons why you consider the assessment to be urgent in the medical record.  This might reflect factors to show any risks associated with delaying the assessment.

Links:

Australian Government – Department of Health, Disability and Ageing: Medicare Benefits Schedule - Note AN.0.19 Category 1 Professional Attendances

There are two parts to this:

• The 80/20 rule relates to services not attendances.  If you provide 80 or more services on 20 or more days in a 12-month period, it will be automatically deemed “inappropriate practice” and referred to the director of Professional Services Review (PSR).
• When you provide slightly less than 80 services in a day, Medicare may still have concerns that the quality of care you provide is inadequate.  Avant has seen cases where Medicare raised concerns about doctors who provided 60 or more daily services for a prolonged period.  This pattern of billing is likely to come to the attention of the Practitioner Review Program, which may require you to undergo an interview with them.

Additionally, the 30/20 rule applies specifically to telephone consultations billed to Medicare. If you provide 30 or more telephone consultations per day on 20 or more days in a 12-month period, it will be automatically deemed “inappropriate practice and referred to the director of PSR.

Links:

Australian Government – Department of Health, Disability and Ageing: Commencement of new prescribed pattern of services – 30/20 telephone rule

Australian Government – Department of Health, Disability and Ageing: Prescribed pattern of services – What you need to know

Australian Government – Department of Health, Disability and Ageing: MBS telehealth services from January 2022

No.

The Department of Health, Disability and Ageing has advised that both the patient and health service provider must be physically located in Australia.

They have also flagged that data matching laws allow them to cross check immigration records of both patients and doctors.

If it is identified that either you or your patient were overseas at the time of claimed services, the Department is likely to require you to repay the amount paid for each service, and you may be the subject of further regulatory action.

Yes.  For a personal attendance, only the time spent face-to-face with the patient can be claimed in relation to a time-dependent Medicare benefit.  For telehealth consultations, only the time the patient is on the telephone or video call with you can be counted towards the minimum time component for a time-dependent Medicare item number.

Only the time spent dealing with the patient’s health condition, which the MBS says is the time the patient receives “active attention”, can be counted towards a minimum time requirement.  There may be cases when the time required for a particular patient is not evident from the clinical complexity of the patient’s health condition, such as if the patient requires more time because they have an impairment or require an interpreter to communicate.  The time required to treat the patient can be claimed if the patient’s circumstances add to the clinical complexity, as long as the records reflect the reason why more time was required.

If you are still unsure after reading the description and explanatory memoranda for the relevant item number you can email medicare.prov@services.australia.gov.au or askMBS@health.gov.au to obtain written clarification from the MBS.  The MBS website also has a range of factsheets that may assist (MBS Online - Current Factsheets).

Fulfilling your obligation to the MBS is not only about billing the correct item numbers but also requires you to understand and comply with all aspects of appropriate practice.  You should therefore ask experienced peers about their practices in relation to the item number.

Links:

Australian Government – Department of Health, Disability and Ageing: AskMBS email advice

Australian Government – Department of Health, Disability and Ageing: Ask MBS Advisories

Avant collection: Medicare: what you need to know

Avant factsheet: Medicare compliance

Services Australia: Latest changes and news

Services Australia: MBS online

Essentially, if a practitioner bulk bills for a service, this means that they agree to accept the Medicare benefit as full payment for that service.  Nothing else (bandages, extra booking fees, etc) can be charged for that service.  The one exception is when a patient is provided with a vaccine from the practitioner’s own supply held at the practice.  This is only for general practitioners and other non-specialist practitioners for certain item numbers listed in the explanatory note, and only for vaccines not available for free through federal or state funding.

Links:

Australian Government – Department of Health, Disability and Ageing: Medicare benefits schedule - Note GN.7.17 Billing Procedures

The starting point is that a public patient in a public hospital should be treated free of charge if the patient has a current Medicare card and the treatment is clinically necessary.

It is possible to also bill Medicare if your patient elects to be treated as a private patient in a public hospital (and they are Medicare eligible).

There are some basic requirements:

• The patient must give their informed financial consent and their agreement to be treated privately must be in writing.
• Patients must have a choice of doctor.
• Doctors treating the patient as a private patient need to have private practice rights (as is the case with VMOs), must not be doubly paid for the service (must provide services other than in the course of their employment) and must follow the requirements for billing Medicare set out in the MBS as all doctors billing Medicare must do.

Links:

Avant factsheet: Medicare compliance 

No.

The Health Insurance Act 1973 (Cth), which is the legislation that outlines the system under which Medicare payments are made, defines a “professional service” for which a Medicare benefit can be claimed as a clinically relevant service, other than a diagnostic imaging service, that is rendered by or on behalf of a medical practitioner.

It also states, as do the MBS explanatory notes, that to claim a benefit from Medicare the medical practitioner must personally attend the patient before a "consultation" is regarded as a professional attendance.

This applies to children as well as residents in aged care facilities.

It also includes telehealth.  The requirement that the patient is present is the same whether the consultation is face-to-face, by video or by telephone.

MBS Online clearly states that telephone attendances or any situation where the patient is not in attendance will not attract a Medicare benefit (AN.0.5). Note AN.0.5 | Medicare Benefits Schedule

Subject to any specific restrictions, you may bill more than one MBS item for a patient on a single occasion provided each item is medically necessary for the appropriate treatment of the patient and all necessary elements of each service are met.

There are many specific restrictions that apply to particular items or groups of items in the MBS, including where one service is rendered ‘in association with’ another and the item descriptor includes a phrase such as “where no other procedure is performed”, “not being a service associated with a service to which XYZ item applies” and several others.  It is, therefore, always important to have carefully read the full item descriptor and any applicable explanatory notes for the services you bill by searching MBS Online.  Another example would be when a chronic condition management plan item is billed, another consultation item cannot also be billed.

You cannot bill multiple items to different patients at the same time, for example, where a family attends a consultation.

There are some general principles that provide a framework for understanding what can or can’t be billed.

A foundational principle is the ‘complete medical service’ principle, which means that each Medicare service must fully meet all elements of the MBS item on its own.  For example, if a major surgery involves several procedures that could otherwise be billed as individual procedures but which are part and parcel of the major surgery, only the major surgical item can be billed.  Conversely, if each necessary procedure can ‘stand on its own’ and each descriptor is fully met, each can billed. All aspects should be adequately documented in the medical record to substantiate the claim/s. 

The Services Australia website provides information on common reasons why claims are rejected.  Error codes are provided to show the reasons why Medicare claims are rejected. See links below. Claims may be rejected because of an issue with how the claim was submitted (return codes are used), or because of an issue with the information submitted (reason codes are used, for example, incorrect Medicare item number).  If you review the code provided and still require further information you can call Medicare Health Professional Online Services (HPOS) on 132 150 and select option 6 (Electronic Claiming including Online Claiming), or the eBusiness Service Centre on 1800 700 199 and select option 3 (Electronic Claiming including Online Claiming).

Links:

Services Australia: Look up a Medicare reason code 

Services Australia: Look up Medicare EasyClaim return codes

Services Australia: Managing rejected claims

Yes, you do.  Regardless of who processes the amount claimed under a provider number, if there is any question about an amount to be recovered by the Department of Health, Disability and Ageing the primary debtor will always be the doctor whose provider number is used to make the claim. 

If you have a provider number and are rendering services you are a part of this system and you will be considered responsible for all services you claim.  This applies regardless of the circumstances in which the services are rendered, whether they are bulk-billed or not, whether provided in a hospital or practice context, and regardless of the extent of your involvement in checking or submitting the claims to Medicare.

Even if your employer says they will indemnify you for billing errors, if your MBS billing practice is found to be inappropriate or incorrect (except when a shared debt determination is made by the Department), you will be responsible for any penalties or repayments.  Accordingly, it is in your interest to maintain tight control over your provider number and what is being billed under it. 

If you do have to pay penalties or repayments to Medicare, reimbursement from your employer would be a separate matter between you and your employer. There is no guarantee that an employer would reimburse for any payments required to be made by Medicare, even if there is an agreement to indemnify.

One penalty for incorrect billing of item numbers can be a period where you are not allowed to bill those item numbers.  It is unlikely any employer indemnity would include compensation to you for that time.

In many practices the administration of Medicare services is generally looked after by staff rather than by the doctor providing the service.  This can be a convenient and efficient system that, when done properly, can assist to ensure you meet the item descriptors and are billing appropriately.

However, as the consequences rest with you, you must be satisfied that billings are being undertaken correctly.  Ideally, you should sign off on all claims being made under your provider number before the claim is submitted, and you should retain a copy of all claims made.

The Department uses data analytics to identify and target compliance activities. It compares practitioners to one another to identify outliers. However, before it gathers information about you, the Department is rarely aware of the specific characteristics of your practice. Read the letter carefully and determine what the letter is asking you to do.

Letters from the Department come in different formats requesting a variety of responses.

If the letter notifies you that your practice with a particular item number is different to that of your peers (for example, you may use it more often), you do not necessarily need to do anything however we would recommend you take the opportunity to review your practice and make changes if required. The letter has generally been sent for a reason and by acting you may prevent further issues. You should have clinical reasons and medical records to substantiate every item number that you bill.

Some letters do require you to “review and act now”. It may identify that you have been billing outside the norm and ask you for an explanation. The letter may come with a schedule (list) of your billings that you are required to review. You might then consider making a ‘voluntary acknowledgment of incorrect payments’ if any claims do not meet the criteria in the checklist.

Alternatively, you may receive a letter informing you that you need to attend an interview as part of the Practitioner Review Program. This letter will inform you of the time and date of your interview and will identify the concerns that you will be required address in the interview.

You should notify Avant if you receive correspondence from Medicare that requires you to act on it or if you have any questions. Please follow the link to submit your notification online and securely upload relevant documents.

If you consider the letter to be urgent you can also telephone the Medico-legal service on 1800 128 268.

The Department of Health, Disability and Ageing often uses data analytics to identify and target compliance activities. It compares practitioners to one another to identify outliers. However, before it gathers information about you, the Department is rarely aware of the specific characteristics of your practice.

The vast majority of doctors bill correctly. If you have received a letter from the Department it does not automatically mean that you have billed incorrectly or that you will have to pay money back.

The Department conducts a number of compliance activities and specific letters will be sent in accordance with those. Some of those activities include:

• Targeted campaigns - where possible non-compliance is identified. You may inadvertently not comply with the descriptors of MBS item numbers. The Department systematically reviews claims made for MBS and associated incentive items, along with PBS prescriptions. It will decide to send letters to doctors it suspects may be using particular item numbers incorrectly and/or if the patient/consultation is not in accordance with the eligibility criteria. A high number of billings of a particular item number, compared to your peers, may also trigger a letter from the Department.
• Professional review if there is the potential of inappropriate practice. The Department reviews the items that you charge for and the degree of variance from others in your specialty. The Department may decide to include you in the Practitioner Review Program if it is concerned that the reason for the variance is because of a lack of clinical indication.
• Suspected fraudulent activity.

Remember, you may be doing everything right but because of the circumstances of your practice or the clinical areas that you focus on, you may sit outside of the normal range for a particular item number.

The Department has sophisticated methods to detect when doctors may have claimed a benefit incorrectly.

Some of these include:

• comparing the claiming behaviours and patterns of doctors to identify inconsistencies between peers
• identifying remarkably high patterns of item usage and or unusual item combinations
• detecting patterns learned from previous cases of incorrect claiming
• investigating tip offs.

The Department are interested in a wider range of concerns and use of data analysis and data matching to identify more specific concerns related to the requirements for each item number – not just ‘over-servicing’ anymore.

It is our experience the Department will closely scrutinise the following issues in relation to the use of MBS item numbers:

1. Is there a clinical necessity for use of the item number?
2. Would the service be considered clinically relevant by your peers?
3. How will the patient benefit from use of the item number?
4. Have you provided the appropriate level of clinical input for the services rendered?
5. Have you met all the MBS number item requirements?
6. Do your records contain enough information to support claiming each Medicare item?

 We have four key recommendations to minimise the risk of compliance action from the Department.

Avoid professional isolation 

Stay in touch with your peers – talk to them about the way you bill Medicare.  In the Departments Medicare compliance, ‘inappropriate practice’ can be established if any aspect of your conduct in relation to Medicare services is deemed unacceptable to your peers.  This may include the adequacy of your medical records, the level of services rendered or the appropriateness of prescriptions.  Practising in a manner that is different from your peers is not necessarily inappropriate. However, your capacity to know and consciously employ the distinction is only valid if you understand what common practice is and how you are deviating from it.

It is, therefore, essential that you keep up to date with your clinical knowledge and your peer network.  Practising in isolation from your peers can lead to a host of clinical and medico-legal issues, including variance in Medicare services that may attract scrutiny or criticism.

If you hear of or think of ways to increase your Medicare billings that are not consistent with what your peers are doing, it is unlikely that the Department will consider that billing to be appropriate.

Ensure that you keep up to date with the Medicare billing rules 

Regularly check MBS Online (MBS Online - MBS Online) to stay up to date with the full item description for all Medicare item numbers that you bill, as well as the relevant explanatory notes.

Maintain control of your billings

By maintaining control over your billings you can be confident that any medical service billed under your provider number is clinically relevant and medically necessary.  Be careful not to rely on practice support staff to make final decisions about which item numbers to bill.  All instructions to bill MBS items should be communicated in writing by you to the practice staff.  No MBS item numbers should be invoiced to Medicare unless instructed in writing by you as the holder of the provider number. 

At the end of each working day request and review a list of all item numbers billed so you can keep track of your Medicare billings.  You should retain these documents for your records.

Good documentation

The legal and professional requirement to keep appropriate medical records is reinforced by Medicare legislation. It says that when you make a Medicare claim for a service, you must maintain an adequate and contemporaneous medical record of the service.

Be sure to record enough details that explain why the service was needed, the clinical input you provided and why the item number was billed. Very brief notes, such as ‘script written’ with no record of presenting complaint or patient history or examination, are likely to be questioned.

At a minimum, ensure you address:

• Reason for presentation
• History
• Examination
• Investigations
• Diagnosis (provisional or final)
• Management plan

Links:

Avant podcast: It happened to me: Medicare compliance letter

An audit is an evidence-based assessment that determines whether all the elements required for a particular benefit have been met. The Department of Health, Disability and Ageing conducts audits for the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS), Child Dental Benefits Schedule and Incentives Program.

Audits do not review the clinical appropriateness of your treatment decisions.

Generally, you will be sent a letter that will explain the audit.

It is likely that you will be notified of a concern and asked to produce documentation that supports your charging of a particular MBS item number. This is known as a ‘Notice to Produce’.

The Notice to Produce will explain the Department’s concern, details of the benefit or service that needs to be substantiated and the type of information that will help substantiate those services. That information will likely be in your medical records.

If your documentation does not confirm that all elements required for a particular item number have been met, then you may be required to pay back funds to Medicare.

You should send all of the correspondence to Avant so we can assist you.

Please follow the link to submit your notification online and securely upload relevant documents. We can then assist you to understand what the next steps will be.

 If the matter is urgent you can also call the medico-legal advisory service on 1800 128 268.

Make sure you are clear about what the Department of Health, Disability and Ageing is asking you to do. If the list of files you are asked to review is extremely long it may be possible to start with a random selection of files to determine if there is a trend or an obvious reason for the Department’s concern that you can respond to without the need to review all the files on the schedule.

You should contact Avant if you have been sent a schedule of claims. Please follow the link to submit your notification online and securely upload relevant documents. We can then assist you to understand what the next steps will be.

 If the matter is urgent you can also call the medico-legal advisory service on 1800 128 268.

In the first instance, you should contact us for advice. If you have any correspondence from the Department follow the link to submit your notification online and securely upload relevant documents. We can then assist you to understand what the next steps will be.

If the matter is urgent you can also call the medico-legal advisory service on 1800 128 268.

You will need to notify the Department of Health, Disability and Ageing as soon as possible if you notice any errors in what you have claimed from the MBS or other benefit schemes. You can do this by filling out a voluntary acknowledgment of incorrect payments form.

After you have completed this form, the Department will contact you to confirm the amount that you will need to repay.

If you have any correspondence from the Department of Health, Disability and Ageing you should send it to Avant so we can assist you. Please follow the link to submit your notification online and securely upload relevant documents. We can then assist you to understand what the next steps will be.

Do not ignore the correspondence. Being proactive by informing the Department will place you in the best position to manage the situation.

In some situations, such as following an audit process, making a voluntary acknowledgement may increase the chances that your matter will be resolved without progressing to the next step in the disciplinary process.  This will hopefully minimise future action.  However you need to carefully consider this decision.

Repayment of incorrectly claimed funds demonstrates that you are being open and honest, which may assist in allaying concerns that the Department has relating to your billings.

Also, if you have claimed a benefit incorrectly an administrative penalty may also apply. In some cases, a voluntary acknowledgement can help reduce that administrative penalty.

Link:

Australian Government – Department of Health, Disability and Ageing: Voluntary acknowledgment of incorrect payments

The type of information that the Department of Health, Disability and Ageing will require will depend on the type of claim that needs to be substantiated. You do not have to provide the entire file of a patient and you can censor information or provide excerpts. The Department has prepared the Health Professional Guidelines to help you understand what documents can be used to substantiate the services being audited.

Any personal information about your patients collected during an audit is kept securely by the Department.

The Australian Privacy Principle 6 in the Privacy Act 1988 allows you to give this type of information to the Department for the purposes of an audit. See link below.

Link:

Australian Government – Department of Health, Disability and Ageing: Health professional guidelines

Australian government – Office of the Australian Information Commissioner: Chapter 6: APP 6 Use or disclosure of personal information

No. You are not required to notify your patients.

You will know of the outcome of the audit before you are advised if you owe money to the Department of Health, Disability and Ageing. If you disagree with the outcome, you can submit an application to review the decision.

If you do not provide the documents relating to the claims being audited you may be subject to a civil penalty, which is similar to a fine.

You can find more information about Medicare audits on the Department of Health, Disability and Ageing website.

Link:

Australian Government – Department of Health, Disability and Ageing: Our Medicare compliance approach Australian Government Department of Health and Aged Care 

There are two review programs with similar names the Practitioner Review Program (PRP) and the Professional Services Review (PSR) – check which information you require.

The Practitioner Review Program (PRP) monitors Medicare data to identify and examine variations that may indicate you have engaged in inappropriate practice. The variations examined are those that demonstrate you are practising in a way that is statistically and significantly different from your peers.

The Department of Health, Disability and Ageing considers Medicare data, which is made up of the claims you make to Medicare and PBS prescribing data.

Simply, it means any aspect of your conduct in connection with providing or initiating services that would be unacceptable to your peers.

The meaning of inappropriate practice is found in legislation: Health Insurance Act 1973, section 82.

Generally, it relates to:

• a doctor providing or initiating Medicare services or prescribing or dispensing PBS medicines in a way that would be considered unacceptable to the general body of the doctor’s peers
• the 80/20 rule. This means that a doctor has rendered or initiated 80 or more professional attendance services on each of 20 or more days in a 12-month period. For more information on this rule, please visit the Department of Health, Disability and Ageing website.

The Department of Health, Disability and Ageing will consider whether:

• the service you provided met the requirements of the MBS or PBS item descriptor, including the clinical and medical relevance of the service
• you kept adequate and contemporaneous records for the Medicare or PBS services that you provided or initiated. These requirements can be found in the Health Insurance (Professional Services Review) Regulations, and include that:
  • the record includes the patient’s name
  • the record contains a separate entry for each attendance by the patient for a service
  • each separate entry includes the date on which the service was rendered or initiated, provides sufficient clinical information to explain the service, and is completed at the time or as soon as practicable after the service was provided or initiated
  • the record is sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record
• your services contravened the 80/20 rule.

Link:

Australian Government: Health Insurance (Professional Services Review Scheme) Regulations 2019

The PRP program is not linear in that you can jump steps in the process.

Initial contact: may be a phone call followed by a letter outlining the Department’s concerns.

Interview: you will probably get invited to an interview with a medical adviser from the Department. This is an opportunity to talk more about your practice and the alleged anomalies with your billings. Before this interview, the Department does not know specifics about your practice or the patients you treat. The data it has is simply statistical. There is a set format to this interview. The Medical Adviser from the Department will usually conduct the interview over the phone.

Submission: If questions remain following the interview, you may be asked by a senior doctor (Delegate of the Chief Executive Medicare) at the Department for further information via a written submission. If you get to the submission stage, the most likely outcome is that you will be referred to the PSR.

At the end of this process or at any stage prior, there are three possible outcomes:

• All concerns are address and there is nothing further for you to do.
• Some concerns remain and so you are given a review period (usually 6 months) where the PRP reviews your claims. This gives you the opportunity to improve your practice.
• You get referred to the Professional Services Review Program (PSR)

Link:

Australian Government – Department of Health, Disability and Ageing: Practitioner Review Program

The possible outcomes of the PRP are:

1. No further action will be taken if the Medical Advisers (doctors employed by the Department) no longer have concerns after meeting with you or after you provide them with extra information.
2. A review of your Medicare data will take place for a period – usually six months – if some  concerns still exist.
3. Referral to the Professional Services Review if significant concerns still exist.

You can find more information about the Practitioner Review Program on the Department of Health, Disability and Ageing website.

If you have been referred to the PSR we recommend you contact us immediately. If you have already been in contact with Avant and:

• If you are already assigned a Claims Manager, please contact them directly. We can then assist you to understand what the next steps will be.
• If you do not have a claims manager assigned, Please follow the link to submit your notification online and securely upload relevant documents.
• If the matter is urgent you can also call the medico-legal advisory service on ph:1800 128 268.

Familiarise yourself with the documents that the PSR has sent you, including concerns and statistics about your practice. You should also familiarise yourself with the item descriptors that match the PSR’s concerns. These item descriptions can be found at MBS online.

Consider informing people close to you that you have been referred to the PSR. This is your choice but can be beneficial to your wellbeing to have the support of those you trust during this process.

For more information about the process please visit the PSR website.

The PSR process begins at the last stage of the PRP . The PSR process is independent from the Department of Health, Disability and Ageing (Medicare). If the Department request the Director of the PSR to review your provision of services, the Director will consider the information and material. If it appears that you engaged in inappropriate practice the Director will conduct a review.

To do this the PSR Director will acquire a random sample of the services that you billed and will ask for the corresponding medical records. The PSR Director will review these and prepare a report. Before completing the report, the Director may meet with you to discuss the billings and records.

When you receive this report you will have the opportunity to make submissions. We can assist you with this part of the process.

At this stage, the Director has a few options. These include:

• that no further action is required
• to enter an agreement with you in which you must acknowledge you engaged in inappropriate practice and will be likely repay money relating to the services. The Director can also disqualify you from billing to Medicare for a specified period
• refer you to a committee of your peers for a hearing to decide if you engaged in inappropriate practice. For more information on the Review by a Committee please visit this website.

If the Director of the PSR is concerned that you have not complied with professional standards or that you have caused risk to somebody’s health, a referral can be made to Ahpra or another regulatory body.

The Shared Debt Recovery Scheme is a way the Department can share a debt that it is owed following a compliance audit. This means that rather than the doctor being responsible for all the debt that is owed to the Department, the debt can be shared between the doctor (the ‘primary debtor’) and another person or organisation (the ‘secondary debtor’) in certain circumstances.

The primary debtor will always be the doctor whose provider number is used to claim from Medicare.

The secondary debtor will most likely employ or engage the primary debtor. However, it could be any relationship between the two that relates to claiming from the Medicare Benefits Scheme.

You will receive a letter from Medicare identifying concerns with your practice.

At this stage the letter may invite you to provide further information regarding a possible secondary debtor. The Department will review that information and determine if it will notify the secondary debtor.

You, as the primary debtor, and the secondary debtors will each have an opportunity to make submissions on whether the debt should be shared and, if so, the percentage that each debtor should owe.

The Department may then make a share debt determination.

A secondary debtor will not exist in all cases. For this to happen there must be a relationship between you and the secondary debtor (ie, employment, engagement or another arrangement related to the charging of Medicare).

Issues the Department will consider include:

• if the secondary debtor controlled or influenced the making of the false or misleading claim. For example, the practice that employs you predetermines item numbers that are charged for certain services before a consultation
• if the secondary debtor received a financial benefit as a result of the false or misleading claim. For example, the practice may have received a percentage of the billings you charged.

The Shared Debt Recovery Scheme applies to Medicare compliance audits that occur after you have received payments from Medicare for the care provided.

The Shared Debt Recovery Scheme will not apply:

• to claims adjustments that occur routinely as part of health practice, where you alert the Department to an error to correct the claims record
• if you make a voluntary acknowledgement of incorrect payments such as after receiving a letter asking you to review your billings or following a targeted campaign (where Medicare has sent you a letter highlighting an anomaly in your practice)
• to debts resulting from inappropriate practice following referral to the PSR
• to debts resulting from a false or misleading statement that can be shown to have been made by someone other than the practitioner
• to debts arising where one party has, without the knowledge of the other, engaged in criminal conduct (fraud) in relation to Medicare claims or billing.

Under the regulations, the default position is that the primary debtor will pay 65% of the debt and the secondary debtor will pay 35% of the debt.

However, the Department of Health can consider any arrangements that were in place between the parties and what influence or control the secondary debtor may have had over the billing of services when determining the final proportion and amount owed by each party.

If you are the subject of a Medicare audit you will receive a letter containing a request for documents. The letter will clearly identify if the Shared Debt Recovery Scheme could apply in relation to that audit.

No. The Shared Debt Recovery Scheme is not intended to make receptionists or administrative staff responsible for debts from services billed on behalf of a doctor. However, the practice may be liable as a secondary debtor.

Any person found to have billed Medicare services against your provider number without your knowledge may be held responsible for the entirety of any Medicare debt and criminal prosecution may be pursued.

The Department is not bound to any terms in a contract between parties. It will make the debt determination using the criteria above. The Department has legislative authority to recover the debt. If there is a contract in place between the two debtors, the department may still apply the Shared Debt Recovery Scheme.

The Scheme began on 1 July 2019. It only applies to audits that started from that date but can still apply to billings from 1 July 2018.