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Health Department speaks on Medicare compliance
The DoHDA reveals the most common non-compliance activities and the practicalities of GPs remaining compliant, as well as acknowledging the anxiety it can cause.
Earlier this year, compliance letters were sent to more than 5000 GPs who may have claimed an MBS item while overseas.
For many GPs, navigating Medicare, its complexities and obligations is a challenging task.
In response, the Department of Health, Disability and Ageing (DoHDA) has told newsGP exactly what its compliance priorities are for 2025, how GPs can remain compliant, and the most common non-compliant activities.
It has also addressed the anxiety which can be caused by navigating the Medicare system.
As a senior medical adviser with the DoHDA, Dr Sarah Mahoney told newsGP the most common non-compliant activities she sees in her role include not meeting Medicare Benefits Schedule (MBS) requirements, providing services which may not be clinically relevant, and failing to keep adequate and contemporaneous records.
‘To identify potential non-compliance, the Department monitors the claiming behaviour of providers through the application of data analytic techniques, industry insights and the assessment of tip-offs and other intelligence,’ she said.
‘This is about ensuring the sustainability of Medicare, the appropriate use of healthcare resources, and the ethical, effective and efficient use of public funding.
‘Equal focus is given to protecting patients and the community in general from the risks associated with inappropriate practice or overservicing.’
Earlier this year, the DoHDA released its compliance priorities for the year ahead, including bulk billing, claiming MBS services while overseas, suspected fraud, duplicate payments, and opportunistic billing.
Already, compliance letters have been sent to more than 5000 GPs who may have claimed an MBS item while overseas.
While in March, letters were posted to more than 1000 doctors found to be prescribing semaglutide under the Pharmaceutical Benefits Scheme (PBS) but failing to follow the criteria.
On Wednesday, Dr Mahoney will speak at an RACGP Medicare compliance webinar alongside college President Dr Michael Wright.
Here, GPs will be given practical advice to help stay compliant and confident in their billing practices.
Previewing the webinar, Dr Mahoney said her main tips for GPs to ensure they comply with Medicare requirements include to maintain the ‘integrity of their provider number and routinely check their claiming’.
‘Avoid double claiming. Unless otherwise specified, all MBS items are complete medical services. A practitioner must perform all the necessary elements of a service before the MBS service is considered to have been provided,’ she said.
‘Maintain current knowledge of the MBS and PBS: review any news updates and fact sheets provided by the DoHDA on its website.
‘Maintain adequate and contemporaneous notes: this supports appropriate patient care as well as the accuracy of the service claimed and its clinical relevance, were you to be the subject of a compliance activity.’
Dr Wright told newsGP the college is working to support GPs with better understanding Medicare compliance within an ‘increasingly complex health system’.
‘It’s really good to take stock and know how we can best comply with the rules and get the best care for our patients,’ he said.
‘It’s important that we know what we’re doing, but also that we understand what Medicare is concerned about.
‘We’re really keen to work with the Medicare team to support better education for GPs so that we’re clear how the system works – I’d much prefer to go to an education event like this than receive a letter in the mail telling me that I’ve done something wrong.’
Dr Mahoney also said the Department recognises that most practitioners are doing the right thing, but also that some GPs may find compliance treatment processes difficult.
‘Practitioners should also be aware that being identified for compliance treatment is not a determination of wrongdoing or inappropriate practice in relation to a practitioner,’ she said.
‘Many of the Department’s processes are designed to give practitioners the opportunity to discuss or respond to any concerns or data identified by the Department as potential areas of difference or concern.’
Prior to claiming an MBS item or writing a PBS prescription, Dr Mahoney said GPs should:
- Check they have met all the MBS item descriptor requirements, including any minimum time requirements, and refer to associated MBS explanatory notes
- Check they have met the PBS criteria, including any restrictions and authority requirements
- Ensure the service they are providing is clinically relevant
- Ensure each prescription provided is clinically relevant
The free
RACGP Medicare compliance webinar will be held on Wednesday 16 July from 7.00–8.00 pm (AEST).
A second RACGP webinar covering the
role of the Professional Services Review, ‘common traps’, billing rules, and overservicing will be held on 22 July from 7.00–8.00 pm (AEST).
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