Current activities
We target compliance activities to the type of non-compliance we identify. This allows for a responsive and proportionate approach to addressing compliance concerns.
Depending on the nature of the compliance concern, compliance activities may be staggered and differ depending on the claiming that was identified.
You may be notified of a compliance activity at a different time to others and you may be asked to take different action.
Approaching 80/20 Prescribed pattern of services 2024-25 Cycle 1
Providers who are approaching the 80/20 threshold for the relevant 12-month data period will be sent an early intervention letter advising of this and directing them to a range of online resources to help them review their servicing behaviours.
Action
We sent education letters on 22 November 2024 to General Practitioners (GPs) who are at risk of exceeding the prescribed pattern of services rule (the 80/20 rules). They are not required to respond to the letters, but encouraged to review their servicing behaviours to ensure that they don’t exceed the 80/20 threshold.
Please direct any enquiries to the departmental contact details provided in the letter.
MBS activities
Magnetic Resonance Imaging (MRI) items for a single body region
The department has identified that some providers may be incorrectly or inappropriately claiming multiple MRI items for a single body region (head or spine) for the same patient during the same attendance. There are co-claiming restrictions on these items with specific requirements that need to be met where more than one item is claimed.
Action
On 8 November 2024, the department sent letters with a schedule of claims (dated 1 January 2023 to 31 December 2023) to those providers who may not have claimed these items correctly. This letter invites these providers to review their claiming and, where incorrect claiming is identified, voluntarily repay any claims that may be incorrect.
Read more about voluntary acknowledgment of incorrect payments.
Please direct any enquiries to the departmental contact details provided in the letter.
Musculoskeletal (MSK) ultrasounds
The department has identified some providers who may be incorrectly or inappropriately claiming musculoskeletal ultrasound items. Two issues have been identified involving these items:
- Providers may be claiming item 55850 where item 55848 may have been the more appropriate item
- Providers may be claiming multiple musculoskeletal ultrasound services before a procedure in instances where a single ultrasound may have been clinically appropriate.
Action
On 8 November 2024, the department sent letters with a schedule of claims (dated 1 January 2023 to 31 December 2023) to those providers who may not have claimed these items correctly. This letter invites those providers to review their claiming and where incorrect claiming is identified, voluntarily repay any claims that may be incorrect.
Read more about voluntary acknowledgment of incorrect payments.
Claiming MBS benefits when the provider was overseas at the date of service
We have identified providers claiming for MBS services while overseas. This type of claiming breaches Section 10 of the Health Insurance Act 1973. The Act states that Medicare benefits are only payable for professional medical services rendered in Australia, to an eligible person.
This compliance activity involves data matching Department of Home Affairs movement records to MBS claiming data. Read more about data matching.
Action
We will send a letter and a list of claims to the identified providers. The letter will invite them to send a reply to us about the identified claiming. We may consider further compliance action as required.
Read more about the MBS audit process.
Incorrect claiming of out-of-hospital MBS benefits
We have identified providers claiming for MBS services at out-of-hospital rates, when they were likely performed in a hospital or hospital setting. This type of claiming breaches Section 10(2) of the Health Insurance Act 1973. Medicare services performed as part of an episode of hospital treatment, or part of an episode of hospital-substitute treatment, are payable equal to 75% of the MBS Schedule fee.
Action
We will send a letter and a list of claims to the identified providers. The letter will invite them to send a reply to us about the identified claiming. We may consider further compliance action as required.
Read more about the MBS audit process.
Prohibited Practices – Pathology
Approved pathology collection centres (ACCs) are often located with health services such as medical clinics. We monitor the lease arrangements and claiming patterns of ACCs to ensure compliance with Part IIBA of the Health Insurance Act 1973. The Act prohibits requesters of pathology and diagnostic imaging services from asking for, accepting, or being offered benefits that may induce requests for services.
Action
We will send a letter to the pathology providers and lessors of ACCs that appear concerning. The letter will ask for information to help us to understand their situation. We may consider further compliance action as required.
Read more about pathology compliance.
PBS activities
Claiming/issuing more than PBS authorised repeats and/or maximum quantity
We have identified Approved Suppliers who may have incorrectly claimed and received payments for supply of Authority required pharmaceutical benefit items.
The number of repeats or quantity exceed the maximum number of repeats authorised by Services Australia.
This is in breach of the National Health Act 1953. Any claim that exceeds the number of repeats and quantity approved by the Chief Executive Medicare or Minister or Delegate are recoverable in full. This is unless the pharmacy can show that the amounts claimed are the same as the amounts prescribed.
Action
We will send a letter and a list of claims to the identified suppliers. The letter will invite them to send a reply to us about the identified claiming. We may consider further compliance action as required.
Read more about the PBS audit process.
Incorrect claiming for extemporaneous creams and ointments
We have identified Approved Suppliers claiming and receiving payments for supply of exceptionally priced prescriptions for extemporaneously prepared creams and ointments. These are high in price, and do not meet legislative requirements in the Commonwealth price (Pharmaceutical benefits supplied by approved pharmacists) Determination 2020 made under paragraph 98C(1)(a) of the National Health Act 1953.
The Monthly Average Price determines the rate at which the Pharmaceutical Benefits Scheme pays for extemporaneously prepared items.
Read more about the Monthly Average Price.
Action
We will send a letter and a list of claims to the identified suppliers. The letter will invite them to send a reply to us about the identified claiming. We may consider further compliance action as required.
Read more about the PBS audit process.
Patient deceased at date of supply
We have identified Approved Suppliers who have claimed benefits for Pharmaceutical Benefits Schedule medications dispensed after a patient’s date of death. This is in breach of the National Health Act 1953. A deceased person is not eligible for pharmaceutical benefits.
Action
We will send a letter and a list of claims to the identified suppliers. The letter will invite them to send a reply to us about the identified claiming. We may consider further compliance action as required.
Read more about the PBS audit process.
CDBS activities
Potential upcoding of cleaning service 88111 or 88115 to 88114 – Stage B
We have identified dental service providers who may be upcoding Child Dental Benefits Schedule (CDBS) service item 88114, when the lower benefit item is clinically relevant or rendered. This type of claiming does not meet the full item descriptor requirements under the Schedule.
Action
We sent letters on 4 September 2024 to dental practitioners with a schedule of claims (dated 1 January 2023 to 31 December 2023) who are suspected of being non-compliant. This letter invites dental practitioners to review their claiming and update their processes to ensure consistency with item descriptors.
Providers can voluntarily repay any claims that may be incorrect. Read more about voluntary acknowledgment of incorrect payments.
Please direct any enquiries to the departmental contact details provided in the letter.
Read more in our Guide to the Child Dental Benefits Schedule.