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.
MBS activities
Approaching 80/20 Prescribed pattern of services
Providers who are approaching the 80/20 threshold for the relevant 12-month data period will be sent an awareness letter advising of this. It will direct them to a range of online resources to help them review their servicing behaviours.
Action
We sent awareness letters on 21 March 2025 to general practitioners (GPs) who are at risk of exceeding the prescribed pattern of services rule, also called the 80/20 rule. A response is not required but these providers are encouraged to review their servicing behaviours to ensure that they don’t exceed the 80/20 threshold.
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 the Department of Home Affairs movement records to MBS claiming data.
Action
We will send education letters and letters with a list of claims to the identified providers. The letter will invite them to send a reply to us about the identified claiming. Further compliance action may be considered as required.
Read more about the Voluntary acknowledgement of incorrect payments.
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.
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 pathology compliance action as required.
PBS activities
Pharmaceutical Benefits Scheme (PBS) Multiple Payments
We identified that some approved suppliers may be receiving more than one PBS payment for the supply of a pharmaceutical benefit. A multiple payment claim for a supply is where either:
- more than one claim is made for the same supply of a PBS medicine, or
- claims for 2 identical prescriptions are made but only one is valid for PBS subsidy.
In both instances above, only one supply of the pharmaceutical benefit is authorised for payment under the PBS.
Action
On 17 March 2025, we sent letters with a schedule of claims to approved suppliers who may have claimed incorrectly. This letter invites these approved suppliers to review their claiming and, where incorrect claiming is identified, voluntarily repay any claims that may be incorrect.
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.
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.
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.
Patient deceased at date of supply
We have identified Approved Suppliers who have claimed benefits for PBS 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.