Warning letters on the way for overseas MBS claims

The Department of Health and Aged Care (DoHAC) will be sending compliance letters in the coming months to more than 5000 GPs who may have claimed an MBS item while overseas.
 
In what it is calling an educational campaign, the DoHAC letter says it is ‘committed to supporting providers to meet MBS requirements’.
 
The letters come as the DoHAC announced its top compliance priorities for 2025 earlier this year which include items that are claimed when either the patient or the doctor are overseas. 
 
Under section 10 of the Health Insurance Act 1973, Medicare benefits are only payable where the service is performed in Australia to an eligible patient. This includes telehealth services.
 
Additionally, provider numbers should only be used for services the GP provides. If a locum or other health provider are taking care of patients while the GP is on leave, the services they provide cannot be billed using that GP’s provider number.  
 
Data matching is being used to cross-reference MBS data with the Department of Home Affairs’ passenger records to identify possible breaches.
 
The DoHAC has advised that audits of around 50 GPs who have billed Medicare while overseas have commenced, with compliance letters to be sent to 5000-plus GPs across May and June.
 
RACGP President Dr Michael Wright recently attended the six-monthly general practice compliance roundtable with other primary care and medical indemnity providers to discuss emerging compliance issues, with overseas billing a focus.
 
‘While the DoHAC recognises that most GPs adhere to the rules, it has concerns about this item and is encouraging us to regularly review our billing process,’ he told newsGP.
 
‘To put it plainly, you cannot bill MBS services if you or your patient are overseas.
 
‘We will continue to work closely with the DoHAC to ensure correct billing rules are followed, while also ensuring an educational approach is used to reduce any unnecessary stress these compliance letters can have on GPs.
 
‘This activity acts as a reminder to ensure GPs and their practice staff are aware that Medicare services cannot be billed while either the doctor or patient are outside Australia, to avoid being the subject of compliance action.’
 
The letters come just weeks after more than a thousand GPs received similar warnings from the DoHAC, after letters raising concerns about their prescribing history of semaglutide were sent out in March.
 
As part of the campaign, the DoHAC is trialling different approaches to what information is sent to individual healthcare providers.
 
The RACGP enquired about the thresholds for providers receiving a letter – or how many times they billed Medicare while overseas.
 
‘The DoHAC advised there are many factors that are carefully considered when deciding thresholds for all compliance activities, and could not share these details at this time,’ Dr Wright said.
 
The compliance letter also asks providers to consider completing a Voluntary Acknowledgement of Incorrect Payments form if they have incorrectly claimed for MBS services while overseas, or if another healthcare provider has claimed for MBS services using their provider number.
 
‘We encourage you to review your billing processes and take any necessary action to ensure future services are not billed to your provider number while you are overseas,’ it states.
 
To reduce the risk of provider numbers being misused, the DoHAC advises GPs to regularly check who has been delegated to claim on their behalf, and ensure their practice maintains good administrative and clinical record keeping, with training for new staff.
 
Dr Wright reminds GPs that they are responsible for what is billed under their provider number.
 
‘There is an option for GPs to close their provider number when going overseas,’ he said.
 
‘Provider numbers can then be re-opened when they return to Australia, to prevent any unintentional use of their provider number for services which occur while they are in another country.’
 
Medicare benefits are not payable in circumstances where the rendering health provider is not in Australia at the time that the service is rendered. The incorrect billing being targeted through this activity therefore concerns the date an MBS service was provided rather than the date a claim is processed.
 
In addition to the Government’s handbook on navigating Medicare, the RACGP has compiled links to a suite of Medicare compliance resources.
 
‘GPs are responsible for ensuring services billed to Medicare meet all legislative requirements,’ Dr Wright said.
 
‘But it’s also worth checking with your medical indemnity provider to see if they have specific advice on claiming MBS services and to ensure your practice team are aware of these billing restrictions.’
 
Full details of the Government’s 2025 health provider compliance priorities are available on the DoHAC website.
 
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