What Medicare compliance is

Healthcare schedules, schemes and programs have requirements bound to them to ensure healthcare practitioners claim the payments correctly.

When a healthcare practitioner provides a specific service to a patient, they may submit a claim which has a set of requirements. They are then rebated for:

  • the Medicare Benefits Schedule (MBS)
  • the Pharmaceutical Benefits Scheme (PBS)
  • the Child Dental Benefit Schedule (CDBS)
  • other incentive payment programs.

We are concerned with ensuring practitioners are claiming their payments correctly and not engaging in fraud by submitting claims incorrectly.

Most healthcare practitioners meet the requirements. When non-compliance occurs it's often accidental.

Who is affected by Medicare compliance?

Most Medicare billing issues are caused by mistake. When a claim is submitted incorrectly it is not just the practitioner that is affected.

Members of the public

Every member of the public has a medical record and clinical history. Incorrect claiming can affect this record and alter how healthcare professionals treat a patient in future instances. Additionally, some healthcare services have limited uses per year. Incorrect billing could impact a person's ability to use these services in the future.

Healthcare practitioners

Incorrect billing practices can leave healthcare practitioners in debt and tarnish their reputation in the community, especially if they have committed fraud.

Financial

  • Healthcare practitioners are responsible for all billing under their provider number or name. They need to repay any incorrect amounts plus any administrative penalties that may apply.
  • Not using the correct item numbers (when submitting a claim) can result in loss revenue for a practice (this is known as 'under-coding').
  • Financial loss can occur when we identify fraudulent activities.
  • Claims resulting from compliance issues may increase a healthcare practitioners insurance premiums.

Administrative

  • Having to resubmit incorrect claims involves practice time and resources.
  • A practice may need to submit a voluntary acknowledgement for any incorrect claims.
  • We may issue a practice with notice to produce documents to substantiate their claim.
  • An audit triggered by incorrect Medicare claims can tie up practice resources.

Reputation

  • If a practice is found to have engaged in incorrect Medicare billing, this may damage a practice's reputation, potentially impacting staff recruitment and retention.

Legal

  • Fraudulent Medicare billing can result in court action being taken against a practice. This can result in prosecutions.

Governmental incentives

The sustainability of Australia's healthcare schemes, schedules and programs relies on practitioners doing the right thing.

Last updated: 
6 May 2022

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