What Medicare compliance is
Health practitioners and organisations must meet legislative requirements when they receive incentive payments, bill or claim for subsidised services or dispense or prescribe subsidised medicines under the:
- Medicare Benefits Schedule (MBS)
- Pharmaceutical Benefits Scheme (PBS)
- Child Dental Benefits Schedule (CDBS)
- Practitioner Incentives Program (PIP).
Medicare compliance is about ensuring health practitioners correctly follow these requirements, in line with relevant laws. Regardless of where they provide their services, this includes:
- medical doctors and specialists
- allied health providers
- dentists and dental practitioners
- nurses and midwives
- pharmacists.
All health practitioners must meet eligibility requirements before they can dispense, prescribe, bill or claim under Medicare programs.
Medicare compliance requirements also apply to hospital treatment. Read more about Medicare billing in public hospitals.
Why Medicare compliance is important
Compliance with legislative Medicare requirements helps to:
- maintain the high quality and integrity of Australia’s healthcare system
- ensure Medicare remains sustainable by paying only legitimate claims.
It benefits patients by ensuring:
- health care is clinically relevant and appropriate
- health records for future treatments remain appropriate
- the correct number of health services that have limited uses each year.
Compliance also benefits health practitioners and practices by preventing the potentially major costs and impacts of non-compliance.
Costs and impacts of non-compliance
For health practitioners and practices, non-compliance can result in:
- fines and debts you’ll need to repay
- reputation damage
- higher insurance premiums that might result from compliance issues
- potential court action in the case of fraud
- administrative burden from having to
- resubmit claims
- submit a voluntary acknowledgement for incorrect claims
- substantiate claims following a notice to produce documents.
Read more about Medicare non-compliance debts and penalties.
Who is involved in Medicare compliance
We are responsible for activities to help health practitioners meet their legal obligations and detect fraud. This includes:
- providing guidance on how to meet their obligations
- developing educational resources
- monitoring claiming patterns
- conducting compliance audits and reviews
- investigating tip-offs
- monitoring MBS and CDBS billing and PBS prescribing practices, as part of the Practitioner Review Program
- investigating fraud.
If we suspect any inappropriate practice by a practitioner or a corporate, we refer cases to the Professional Services Review scheme.
Read more about our compliance approach.
Stakeholders we work with to promote compliance include:
- the Department of Veterans’ Affairs – manages healthcare payments for veterans
- Services Australia – manages payments made under Medicare and its programs, and does compliance audits and reviews for the MBS, PBS, CDBS or PIP
- peak professional bodies – provide support and information to their members
- indemnity insurers – support health practitioners undergoing audits.
How to report suspected Medicare non-compliance
Notify us if you are concerned about the billing or claiming, or suspect fraud of a healthcare practitioner, their practice or their employee.
Find out more about reporting incorrect billing, claiming or suspected fraud.