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On 23 February, the RACGP met with the Department of Health, Disability and Ageing (DoHDA)’s Benefits Integrity Division as part of our ongoing collaboration.
2026 compliance priorities
DoHDA will shortly provide finalised compliance priorities for 2026. These include enduring priorities where persistent risks to the integrity and sustainability of health programs have been identified and focus areas that examine billing over a specified period.
Approaching 80/20
Since 2023, DoHDA has been sending early intervention letters to GPs who are at risk of referral to the Professional Services Review for potential inappropriate practice by exceeding the prescribed pattern of services rule (80/20 rule).
Providers who are approaching the 80/20 threshold for the relevant 12-month data period will receive an early intervention letter. Another round of these letters was sent at the beginning of the year.
If you receive a letter, please take note of DoHDA’s concerns, review your claiming levels moving forward, and contact your medical defence organisation for advice.
Reporting incorrect billing or fraud
DoHDA provides a range of options to report incorrect Medicare billing or suspected fraud. This includes situations where providers have claimed for a service which was not provided, not met the requirements for claiming, or your provider number has been misused.
You can complete the online form, email provider.benefits.integrity@health.gov.au, or call 1800 314 808.
The online form is the preferred reporting method, as it allows the department to thoroughly review the details of your concern with minimal need to seek further information from you. The online form can also direct you to other agencies if your concern is not managed by the department.
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