Strategies to minimise risk - Medicare Billing Assurance Toolkit

There are 10 strategies you should adopt in your practice to identify, manage and prevent the risk of incorrect billing under Medicare:

Page last updated: 06 February 2017

Under each of the strategies we have provided some of the findings from the Department of Human Services 2013 Medicare Billing Accuracy Survey on the factors that influence Medicare billing accuracy. A total of 786 practitioners and practice managers completed the survey.


Strategy 1: Have designated staff whose role includes Medicare billing assurance responsibilities

Your practice can benefit by having at least one person who is the contact point for Medicare billing assurance-related issues.

Why you need this strategy

A designated contact person for Medicare billing assurance-related issues can:
    • oversee and advise of Medicare billing errors that may be happening, and
    • escalate incorrect Medicate billing to senior management

How you can adopt this strategy

Make sure all practitioners and practice staff are fully aware of the contact details of the designated Medicare billing assurance person or people, and when they should be contacted.

Fast fact

Accurate billing of services under Medicare is the legal responsibility of the health practitioner who renders the service that is claimed.
If an incorrect claim is made, the health practitioner may have to pay an administrative penalty. This is in addition to repaying the incorrect amount paid, regardless of employment, contractual or other financial arrangements.
Any person, including non-clinical practice staff, who submits fraudulent claims may also be subject to penalties.

What the Medicare Billing Accuracy Survey showed

Even though accurate billing of services under Medicare is the legal responsibility of the rendering practitioner, at least 25% of survey respondents reported that they did not check whether the MBS item numbers they chose were actually those billed to Medicare.

Handy hint

A summary of the major Acts, Regulations and determinations for the payment of Medicare benefits is available from the MBS Online website.

Toolkit tip

The Medicare billing assurance template has an overview of the possible role and responsibilities of a Medicare billing assurance person.

 

Strategy 2: Have documented Medicare billing procedures

Your practice can benefit from having consistent, streamlined procedures to guide health professionals in correct Medicare billing procedures.

Why you need this strategy

Documented Medicare billing procedures can:
    • provide a single documented reference point for all Medicare billing issues in your practice
    • make it easier to train new health professionals in your practice
    • improve the quality of your practice’s Medicare billing decisions
    • provide reassurance that if your practice were to be reviewed, you could be confident your Medicare claims were correct

How you can adopt this strategy

    • Look at how you are currently doing Medicare billing activities in your practice - include a review of any instruction manuals, lists or systems that are currently used
    • Identify activities where inconsistencies or possible Medicare billing errors could occur
    • Develop a Medicare billing assurance procedure for your practice - make sure it addresses all compliance gaps that were identified during your review
    • Make sure all health professionals are appropriately trained in your practice’s Medicare billing assurance procedures
    • Regularly review and update your practice’s Medicare billing assurance procedures to reflect new practice risks, new business activities and new Medicare requirements

Fast fact

Make sure your practice has Medicare billing procedures in place to minimise or avoid the risk of incorrect billing. For example, if a service that is not part of the specified MBS item was claimed under that item number, then:

What the Medicare Billing Accuracy Survey showed

Practice procedures can have an impact on the Medicare billing accuracy of practitioners—53% of survey respondents reported that they are influenced by practice or business protocols.

Handy hint

Consider including a Medicare billing assurance section in your practice manual.

Toolkit tip

You can use the Medicare billing assurance manual template in this Toolkit as a starting point for developing documented Medicare billing procedures for your practice. 

Strategy 3: Update and fully use your practice software

If your practice uses software to generate Medicare claims, up-to-date and correct Medicare claiming functions assist in achieving correct Medicare billing.

Why you need this strategy

You may be able to produce reports using your practice-based software as part of your Medicare billing assurance process. For example, it may be able to generate standard reports that can be used by your practitioners to quickly review their Medicare billing.

How you can adopt this strategy

    • Make sure your practice software is set up to receive software updates
    • Check your practice software vendor has processes in place to make sure your practice software is up to date with the MBS
    • If your practice software does not automatically update MBS, clearly indicate who in the practice has responsibility for making sure it’s up to date with the MBS changes
    • Allocate sufficient time and resources for all health professionals in your practice to receive training on how to use the software correctly

Fast fact

Practitioners are responsible for all Medicare billing claims made under their Medicare provider number or name, even if the practice software was used to facilitate the process, for example, by automatically pre-populating the MBS item numbers to be billed.

What the Medicare Billing Accuracy Survey showed

Survey respondents ranked practice software settings fourth in the factors that influence Medicare billing accuracy, after the health professional’s level of MBS knowledge, MBS Online useability and practice or business protocols.

Handy hint

You can subscribe to receive MBS Online updates by email on the MBS Online website.

Toolkit tip

The department publishes a list of software vendors that offer Medicare online claiming

Strategy 4: Have effective administrative recordkeeping in place

Effective record keeping in your practice can help with overall efficiency and legal compliance.

Why you need this strategy

Effective administrative record keeping in your practice:
    • improves the efficient day-to-day operation
    • helps record and maintain patient information
    • enables transparent reporting
    • reduces the risk of your practice not being able to substantiate Medicare claims or receiving an incorrect Medicare payment, and
    • if necessary, assists you to respond to a ‘Notice to produce documents’ that is issued to a practitioner or the person in charge of the practitioner’s records

How you can adopt this strategy

    • Establish what processes you need to effectively maintain administrative records and how you can achieve this
    • Collect and store information in a consistent way and make sure all health professionals in your practice follow the same procedure
    • Make sure all health professionals are aware of and understand your practice’s administrative record keeping policies and procedures
    • Know the capabilities of your practice’s software and electronic record keeping systems
    • Provide appropriate software and systems training to all health professionals
    • Allocate sufficient staffing and resources to maintain records
    • Regularly review and update your practice’s record keeping procedures to keep up with best practice and Medicare requirements

Fast fact

Where information is entered on accounts, receipts or Assignment of Benefit forms by an employee of the practitioner, the practitioner claiming payment for the service is responsible for the accuracy and completeness of the information.
The Health Insurance Act 1973 (Cth) enables the department to issue a ‘Notice to produce document to a practitioner or a person in charge of their documents. It requires them to produce documents to substantiate services claimed under Medicare.
Failure to comply with the notice can attract civil penalties of 20 penalty units for an individual and 100 penalty units for a body corporate.

What the Medicare Billing Accuracy Survey showed

A sound knowledge of your computer systems can be useful when providing information required to substantiate a Medicare claim. 94% of survey respondents reported they have computers in their practice’s consultation rooms which have functions for storing and retrieving patient or client clinical records.

Handy hint

We work with a number of health peak bodies to develop guidelines that explain the documents practitioners can use to substantiate services if they are asked to participate in a Medicare compliance audit.

Toolkit tip

Further information about legal obligations when billing under the MBS is available at Health Professional Compliance.

Strategy 5: Notify the department in a timely manner when incorrect billing under Medicare has occurred

If a practitioner incorrectly claims a Medicare benefit, or receives an incorrect Medicare payment, they may have to pay an administrative penalty in addition to repaying the incorrect amount they received.

Why you need this strategy

The penalty for incorrect Medicare payments is a percentage of the amount owed for each incorrect payment. However, if the practitioner voluntarily acknowledges an incorrectly claimed benefit or payment, the administrative penalty may be reduced or avoided completely.

How you can adopt this strategy

    • Have a clear protocol to manage incidents when incorrect billing under Medicare occurs
    • Promote a voluntary disclosure environment in the practice. For example, make it easy and attractive for all health professionals in your practice to highlight and resolve incidents of incorrect billing under Medicare

Fast fact

Section 129AEB of the Health Insurance Act 1973 (Cth) sets out the circumstances when the administrative penalty may be reduced, depending on when the department is notified about an incorrect claim or payment.

The base penalty is 20% of the total amount owed. It can be reduced from 20% to:
    • zero, if the department is notified about incorrectly-claimed benefits or payments before the department contacts the practitioner
    • 10%, if the department is notified about the incorrect claim or payment after the department contacted the practitioner and before a formal ‘Notice to produce documents’ is issued, or
    • 15%, if the practitioner notifies the department about any incorrectly claimed benefits or payments after the practitioner has received the formal ‘Notice to produce documents’, and before the date specified in the Notice
In some circumstances an increased administrative penalty may apply if a Medicare compliance audit has started.

What the Medicare Billing Accuracy Survey showed

Early correction of an incorrect Medicare payment by a practitioner through a voluntary acknowledgement may avoid an administrative penalty. However, at least 25% of survey respondents reported that they do not check whether the MBS item numbers chosen are actually those billed to Medicare.

Handy hint

The Voluntary Acknowledgement of Incorrect Payments form is available online.

Toolkit tip

A list of key provisions in the Health Insurance Act 1973 (Cth) on the consequences of incorrect billing under Medicare is included under the Offences and Practitioner Review Program sections of 'About this toolkit'. 

Strategy 6: Encourage good communication between practitioners and other practice staff

Good communication between practitioners and other practice staff can help ensure the MBS item selected by the rendering practitioner is the actual Medicare item billed.

Why you need this strategy

Medicare billing errors can happen when practice staff other than the rendering practitioner finalise the Medicare billing decision without knowing which MBS item was selected by the practitioner.
Open communication encourages practice staff to consult with the rendering practitioner where they see any issues prior to finalising a claim.

How you can adopt this strategy

    • Encourage all practitioners and practice staff to raise concerns and provide feedback regarding Medicare billing issues
    • Encourage communication in the practice and use the most appropriate method (e.g. email, text messages or face-to-face meetings)
Fast fact Under the Health Insurance Act 1973 (Cth), a practitioner is responsible for incorrect claims made under his or her Medicare provider number or name, regardless of who does the billing or receives the benefit.

What the Medicare Billing Accuracy Survey showed


Even though practitioners may rely on other practice staff to review, check and finalise their Medicare billing, survey results show that:
    • only 77% of practitioners surveyed are informed when changes are made to the MBS item number they had originally chosen, and
    • 63% of survey respondents only receive communication on Medicare billing in their practice on an ad hoc basis (instead of regular scheduled communication activities)

Handy hint

Information sharing and good problem solving go hand-in-hand. Encourage health professionals in your practice to speak up and voice their concerns or ideas about any Medicare billing accuracy issues.
This enables them to take ownership of the issue and to provide input into the actions the practice may take to resolve the issue. 

Strategy 7: Promote knowledge of Medicare billing assurance to all health professionals in your practice

Up-to-date knowledge of Medicare billing practices can ensure incorrect billing is identified if it occurs.

Why you need this strategy

Lack of, incorrect or outdated Medicare billing assurance knowledge may create an environment where incorrect billing under Medicare occurs in the practice and is not identified in a timely way, or not identified at all.

How you can adopt this strategy

    • Be proactive about Medicare billing assurance education. Take advantage of resources from the department, industry associations and professional advisory organisations and promote them widely in your practice.
    • Encourage all health professionals in your practice to undertake the Medicare education and training modules
    • Schedule regular Medicare billing assurance risk assessments (refer to the Practice self-assessment checklist in this Toolkit) and share the assessment outcomes with health professionals in your practice

Fast fact

Under the Health Insurance Act 1973 (Cth), the practitioner is responsible for billing Medicare correctly so the onus is on the health practitioner to make sure all Medicare claims under their provider number or in their name (including claims that may have been finalised by practice staff on their behalf) are made correctly.

What the Medicare Billing Accuracy Survey showed

A sound knowledge of current MBS requirements is essential for accurate Medicare billing.
Survey results showed that 60% of survey respondents who work in large practices (compared to only 43% of survey respondents who work in small practices) initially learned how to use the MBS through informal or on-the-job experience rather than formal training or reference to Medicare publications.

Handy hint

There are a number of handy tools produced by the government to make it easier to keep up with Medicare changes. Visit the MBS Online website and humanservices.gov.au/healthprofessionals to access a wide range of resources.

Toolkit tip

A list of Medicare education resources are available in this Toolkit under resources. 

Strategy 8: Have senior management commit to Medicare billing assurance

Senior management drive the culture in a practice so it’s essential that they are committed to Medicare billing assurance.

Why you need this strategy

It’s essential senior management promote a positive Medicare billing assurance culture to engage, encourage and enable all health professionals to correctly bill under Medicare.

How you can adopt this strategy

    • Encourage senior management to formally recognise the practice’s commitment to Medicare billing assurance through a mission statement or charter
    • Recommend including ‘Medicare billing assurance’ as a standing item in senior management or practice meetings
    • Have a senior manager champion the practice’s Medicare billing assurance approach

Fast fact

Senior management may also have responsibilities under the Health Insurance Act 1973 (Cth)—for example, section 82 refers to circumstances where the employer of a health practitioner may be held liable for causing or permitting an ‘inappropriate practice’ to occur.

What the Medicare Billing Accuracy Survey showed

Survey results showed that only 13% of health practitioners and 9% of practice managers told the practice owner when they discovered that an unauthorised claim was made using the practitioner’s Medicare provider number or name.

Handy hint

Senior management commitment should be visible to all staff.
Consider introducing connecting activities between senior management and health professionals to encourage direct conversations about Medicare billing assurance issues. For example, hold a monthly meeting where a senior manager visits the practice to meet with all health professionals and discuss a specific Medicare billing assurance issue.

Toolkit tip

Consider using the Medicare billing assurance charter in this Toolkit as part of your practice’s mission statement. The charter is an explicit statement of principles to guide correct billing under Medicare. 

Strategy 9: Identify and remove workplace arrangements that may lead to incorrect billing under Medicare

Be proactive in creating an environment that minimises the risk of incorrect billing.

Why you need this strategy

Business incentives in the practice may intentionally or unintentionally influence MBS item number selection and Medicare billing processes by health professionals in your practice.
This may result in incorrect claims under Medicare.

How you can adopt this strategy

    • Reinforce your practice’s commitment to ethical behaviour by displaying a code of ethics in a prominent location, or making it a standing agenda item in practice meetings
    • Regularly review your practice’s Medicare billing protocols to make sure they do not result in or promote incorrect billing under Medicare
    • Ensure health practitioners’ terms of employment do not place them at risk of engaging in inappropriate practice; for example, by encouraging over-servicing

Fast fact

Section 82 of the Health Insurance Act 1973 (Cth) provides that an employer or an officer of a body corporate will be found to have engaged in inappropriate practice if he or she knowingly, recklessly or negligently causes or permits a health practitioner employed by them to engage in conduct that constitutes inappropriate practice.

What the Medicare Billing Accuracy Survey showed

Workplace arrangements can influence Medicare billing accuracy in a practice setting.
The survey showed that survey respondents in large practices were more likely than those in small practices to agree that conditions of employment and remuneration, as well as time pressures placed on practitioners, affect accurate billing under Medicare.

Handy hint

Codes of ethics or conduct are valuable references to make sure that health professionals comply with their professional ethical responsibilities.
View the Australian Medical Association and the Royal Australian College General Practitioners codes or policies on ethical behaviour. 

Strategy 10: Check that your practice’s requesting and referral procedures are compliant

Reduce the likelihood of incentives for referrals resulting in incorrect Medicare billing.

Why you need this strategy

A requester who is employed by a practice is prohibited from receiving incentives for referring patients to pathology or diagnostic imaging service providers who are employed by the practice, or to a particular provider.
The prohibited incentives cover benefits (including salary bonuses) that relate to the number, kind or value of requests made to a provider.

How you can adopt this strategy

Where practice software is pre-configured to automatically populate the request or referral with details of the practitioner referring the service, or types of tests and treatments that are being referred or requested, make sure:
    • the requesting health practitioner is fully aware of the request or referral and has given full approval before the request or referral is made, and
    • all health practitioners are able to review, edit and override the pre-populated details of the request or referral

Fast fact

Part IIBA of the Health Insurance Act 1973 (Cth) prohibits:
    • a requester or someone connected to the requester asking for, or accepting, a non-permitted benefit
    • a provider or someone connected to the provider offering or providing a non-permitted benefit, and
    • the making of certain threats in connection with pathology or diagnostic imaging requests or services
The legislation applies to:
    • anyone able to request pathology or diagnostic imaging services that would be eligible for Medicare benefits (requesters)
    • anyone who renders pathology or diagnostic imaging services that are eligible for Medicare benefits (providers)
    • in the case of the civil penalty provisions in Division 2 Part IIBA, persons connected to requesters or providers including people or companies who employ or engage either requesters or providers, and their executives, and
    • in the case of the offences in Division 3 Part IIBA, anyone who offers or provides a benefit, or makes a threat, with the intention of inducing a requester to request pathology or diagnostic imaging services from a particular provider

What the Medicare Billing Accuracy Survey showed

Practitioners need to review requests and referrals to ensure they are accurate and clinically relevant. Of the 672 survey respondents who use a computerised clinical record keeping system the survey showed:
    • 63% indicated that the practitioner details to whom the referral or request will be sent is automatically populated, and
    • 46% indicated the tests or procedures that the patient requires are automatically populated

Handy hint

A number of transactions may be classed as permitted benefits. For example, the distribution of profits or shares from a pathology or diagnostic imaging business may be a permitted benefit, if the benefit is proportionate to the person’s interest in the body corporate, trust or partnership. Further details of permitted benefits are available on our website and the Australian Government Comlaw website.