Compliance education for health professionals Medicare Billing Assurance Toolkit

A toolkit of checklists, templates and suggestions to make it easier for you to manage risks that inadvertently cause incorrect billing under Medicare

Page last updated: 03 February 2017

About
Why correct billing under Medicare is important
Debt recovery
Offences
Practitioner Review Program

About

We recognise the changing nature of health practices and the important role all practice staff have in ensuring the sustainability of Australia’s health system.

We’re committed to helping health professionals by providing you with the right information and support so you can meet your legal obligations when billing under Medicare. We also want to make it easier for you to manage risks that inadvertently cause incorrect billing under Medicare.

We’ve worked closely with peak health bodies and health professionals to identify ways Medicare billing accuracy can be improved.

A Medicare billing assurance approach is a combination of the policies, procedures, systems and day-to-day activities that are carried out in your practice to ensure accurate Medicare billing.

An effective Medicare billing assurance approach can:
  • reduce the risk of incorrect Medicare billing in your practice
  • help health professionals in the efficient day-to-day operation of the practice
  • improve your practice’s staff procedures and knowledge of how to bill correctly
  • help you promote a culture of compliance in your practice as an effective risk management strategy for Medicare billing decisions, and
  • enhance your practice’s business continuity
This Toolkit is designed to help health professionals comply with the Health Insurance Act 1973 (Cth). The material in the Toolkit is provided as a general reference on the understanding that the Department is not providing endorsed material or professional advice.

Using the Toolkit does not exempt you from Medicare billing compliance responsibilities and does not confer any privilege or exemption in the event of a breach of the Health Insurance Act 1973 (Cth).

All information in this Toolkit is correct as at April 2015.

Why correct billing under Medicare is important

Incorrect billing under Medicare may result in the financial, administrative, reputation-related and legal consequences.

Financial

  • If services have been billed incorrectly under a health professional’s Medicare provider number or name, they will be responsible for repaying the incorrect amount, plus any administrative penalties that may apply
  • Your practice may not be getting the correct Medicare payment if incorrect Medicare Benefits Schedule item numbers are selected (e.g. under-coding may result in less revenue for your practice)
  • Significant financial loss may occur when fraudulent activities go undetected because incorrect billing has not been identified
  • Claims that result from a health provider compliance issue may increase your insurance premiums
  • Health professionals may also be required to pay an administrative penalty under section 129AEA(1) of the Health Insurance Act 1973. The amount of the administrative penalty is calculated in accordance with section 129AEB of the Health Insurance Act 1973.

Administrative

  • Incorrect claims may need to be resubmitted, resulting in a double-up of the claiming process that involves time and resources from your practice
  • Your practice may need to submit a Voluntary acknowledgement of incorrect payments form to the department if an incorrect Medicare claim was made
  • Your practice may be issued with a Notice to produce documents due to a Medicare audit, which requires you to produce evidence to substantiate each Medicare claim covered by the audit
  • Your practice’s business continuity may be adversely affected if health professionals in your practice and practice systems are tied up in Medicare audits that have been triggered by incorrect Medicare claims

Reputation

  • There may be an adverse impact on your practice’s reputation, staff recruitment and retention if your practice is found to have engaged in incorrect billing under Medicare

Legal

  • Fraudulent Medicare billing may result in court action being taken against health professionals in your practice or the practice owner, which may result in prosecution for various offences

Debt recovery

Incorrectly paid Medicare benefits are recoverable under section 129AC(1) of the Health Insurance Act 1973 (Cth).
  1. Where, as a result of the making of a false or misleading statement, an amount paid, purportedly by way of benefit or payment under this Act, exceeds the amount (if any) that should have been paid, the amount of the excess is recoverable as a debt due to the Commonwealth from the person by or on behalf of whom the statement was made, or from the estate of that person, whether or not the amount was paid to that person, and whether or not any person has been convicted of an offence in relation to the making of the statement.
    Read more about Health Professional Compliance.

Offences

Health professionals who are suspected of fraud against Medicare may also be prosecuted under various offence provisions in the Act:

Practitioner Review Program

As well as having to repay incorrectly claimed benefits, pay administrative penalties and be subject to possible prosecution, health professionals may also be reviewed under the Practitioner Review Program.

The Practitioner Review Program reviews health practitioners whose Medicare claiming or Pharmaceutical Benefits Scheme (PBS) prescribing data raises concerns that they have engaged in inappropriate practice.

Section 82 of the Health Insurance Act 1973 (Cth) provides that a practitioner engages in inappropriate practice if the practitioner’s conduct in connection with rendering or initiating services is such that a Professional Services Review (PSR) Committee could reasonably conclude that the conduct would be unacceptable to the general body of the practitioner’s peers.

A health practitioner who is found under the PSR Scheme to have engaged in inappropriate practice may face one or more sanctions.