How to comply with Medicare obligations

As a health practitioner, it is your responsibility to comply with Medicare obligations. It’s important to do the relevant training and understand the requirements and laws that apply. We provide lots of education and support to help you meet your obligations.

Understand when Medicare compliance applies

Compliance and eligibility requirements apply to health practitioners who bill, claim, dispense and prescribe under the:

This includes meeting:

Read more about:

Understand the laws that relate to Medicare

It’s important to understand the laws that govern:

  • what can be claimed
  • who can claim
  • the amount of benefits
  • who manages payments and services
  • who administers Medicare.

Read more about the laws that govern Medicare.

Complete relevant training

We provide educational resources and personal support to help you meet your legal obligations and reduce the risk of incorrect billing under Medicare and claims for payment under the PBS. This includes eLearning modules about:

Read more about what we’re doing to support health practitioners comply with Medicare requirements.

Understand constraints and restrictions

All Medicare items and incentive payments have specific requirements.

For practitioners

You must provide clinically relevant and medically necessary MBS services as intended, in line with:

You must provide clinically relevant and medically necessary CDBS services as intended, in line with:

For prescribers

When prescribing PBS medicines, make sure you:

For dispensers

When dispensing PBS medicines, make sure you:

For practice managers

If you receive Practice Incentive Payments, make sure you:

Bill and claim accurately

You must bill and claim for MBS and PBS items accurately to avoid compliance action, including using the correct item numbers and claiming for practice incentives as required.

To understand your billing and claiming responsibilities:

Medicare billing in public hospitals

Public patients in a public hospital receive services free of charge. However, patients may elect to be a private patient and claim Medicare benefits instead. To ensure appropriate billing, you need to know when patients can claim Medicare benefits when they attend a public hospital.

Medicare billing in public hospitals

There are many situations that can arise in the administration of Medicare billing in public hospitals. These case studies have been constructed to help you know how you can improve your Medicare billing practices.

Report incorrect claims

Let us know as soon as you realise you have made an incorrect claim. You must repay the incorrect payment amount.

A penalty may apply to any amount owing (the debt accrued). However, no penalty will apply to voluntary acknowledgements.

We routinely monitor Medicare billing and claiming for potential inappropriate practice through different compliance activities, including under the Practitioner Review Program. We also follow up on tip-offs that may suggest health practitioners have claimed Medicare incorrectly.

Keep accurate records

As a health practitioner, you are responsible for keeping accurate records, and being able to produce them to substantiate your Medicare claims if we request them as part of a review or audit.

Records should:

  • clearly identify the name of the patient
  • contain a separate entry for each attendance by the patient
  • include the date when the service took place
  • contain adequate and clear clinical information
  • be completed at the time of service or as soon as possible after

Read our guidelines on maintaining good record keeping standards within your practice.  

Ask for advice

If you are unsure, the AskMBS email advice service helps health professionals and practice managers understand and comply with Medicare claiming requirements.

We give advice on how to interpret and apply MBS items, explanatory notes, and associated legislation. We publish advisories that summarise common issues and our responses to them.

View more Medicare contacts.

How we support you

We support health practitioners to correctly bill, claim, prescribe and dispense under Medicare through:

Read more about what we’re doing to help you comply with your Medicare obligations.

 

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