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DoHAC reveals compliance priorities for 2025

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Medicare is a complex system to navigate, with compliance a common concern among GPs.
 
This week, the Department of Health and Aged Care (DoHAC) published its top compliance priorities for 2025, flagging eight areas of concern that it will be keeping an eye on over the next 12 months:

• Bulk billing
• Specialist and consultant physician claiming of attendance items and management plans
• Claiming Medicare Benefits Schedule (MBS) services while overseas
• Suspected fraud
• Duplicate payments
• Opportunistic billing and emerging business models
• Inappropriate claiming of high-cost Pharmaceutical Benefits Scheme (PBS) medicines
• Open and uncertified PBS claims

The DoHAC has said it ‘regularly reviews’ its priorities and that they are chosen based on their ‘characteristics’, as well as consideration of the ‘seriousness and scale of the harm posed to the Medicare system’.
 
‘Compliance priorities may relate to new and emerging risks, and those the department considers to be enduring,’ it said.
 
‘Our published compliance priorities reflect our commitment to act.’
 
Meanwhile, the DoHAC has also released its Health Provider Compliance Strategy 2025–30, in which it outlines its responsibility and approach to ensuring the integrity of Federal Government health program payments, which include the MBS, PBS, and Child Dental Benefits Schedule (CDBS).
 
Dr Tony Bayliss is the RACGP’s Medicare compliance lead GP and a member of the RACGP Expert Committee – Funding and Health System Reform.
 
He told newsGP the college has seen an ‘increasingly collaborative approach’ from the Federal Government when it comes to addressing compliance, which it has strongly been advocating for.
 
‘GPs rely on social license and it’s important that we’re held to account; it’s not our money, it’s taxpayers’ money,’ Dr Bayliss said.
 
‘But on the other hand, I think it’s good that there’s a balance between ensuring the rules are upheld, but also having a pragmatic approach and realising that the vast majority of incorrect billings are inadvertent rather than deliberate.
 
‘The Philip Review showed that the vast majority of GPs are doing the right thing; it’s just a complicated system. So, a collaborative and educational approach works in the best interests of the DoHAC, the college, and GPs as well.’
 
The Queensland GP cited recent ‘education letters’ issued by the DoHAC to doctors found to be prescribing semaglutide under the PBS but failing to follow the criteria, as a good example.
 
‘There’s a recognition that GPs may have accidentally or inadvertently prescribed outside of Medicare guidance and so an educational, rather than an enforcement, view has been taken, and we encourage that,’ Dr Bayliss said.
 
‘It also reflects the fact that there’s been a lack of clarity or consistency about the criteria to prescribe. So, it’s good that the Government reflects that.’
 
In 2023–24, the Government’s health programs accounted for more than $48 billion in taxpayer expenditure.
 
In its latest five-year strategy, the DoHAC has said it uses a ‘risk-based and proportionate’ approach to addressing health provider compliance.
 
It claims to do this by aiming to prevent incorrect claiming by ‘making it harder to get it wrong’, enable correct claiming by ‘supporting providers to get it right’, and ‘effectively address’ non-compliance when it occurs.
 
To detect any non-compliance, the DoHAC says it monitors claiming data, collects intelligence and carries out targeted data analysis. This is managed across five broad themes, including incorrect claiming and prescribing, business arrangements that seek to inappropriately maximise payment of benefits, possible inappropriate practice, and fraud.
 
Dr Bayliss acknowledged that receiving a compliance letter from Government can be intimidating but reassures that it does not necessarily signal future disciplinary proceedings.
 
‘The first step is to, where possible, take a moment and have another look at it,’ he advised.
 
‘Obviously, getting support from your peers can be important and talking to indemnity providers can also give people some comfort. But we all take a lot of pride in our work and sometimes these things are going to happen, and you just have to address them as best you can.
 
‘Sometimes they’re just letting you know that it would be worthwhile having a look at your prescribing and to see what changes you could make.
 
‘But the main thing, I think, is really to look after your mental health. Even if nothing comes of it, it can be quite an intimidating experience. While scrutiny can be threatening, it’s also a necessary part of our process and part of our social licence.’
 
Dr Bayliss acknowledged that compliance can be particularly challenging for GPs practising in Australia via the expedited specialist pathway. He says while they have excellent clinical skills, they may be at a disadvantage when it comes to understanding how Australia’s billing system works.
 
‘Especially if they’re coming from capitation,’ Dr Bayliss said.
 
‘The RACGP, working with DoHAC’s Benefits Integrity Division, can help these clinicians with their transition to Australia and the college will be preparing a suite of education resources to help them with that transition.
 
‘In the meantime, we do have resources on our website, and we will be having some webinars that will be available live, but also on a recorded basis, to help people to better understand how compliance and billing relates to their practice.’
 
While the DoHAC has published its key compliance priorities for the year, it did note that priorities ‘may evolve in response to emerging risks’.
 
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bulk billing compliance strategy DoHAC health provider Medicare

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