How to comply with Medicare obligations

Understand when Medicare compliance applies

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

• Medicare Benefits Schedule (MBS)
• Pharmaceutical Benefits Scheme (PBS)
• Child Dental Benefits Schedule (CDBS)
• Practitioner Incentives Program (PIP).

This includes meeting:

• legislative requirements
• your profession and specialisation education and registration requirements
• relevant accreditation standards
• eligibility requirements to bill, claim, dispense or prescribe under Medicare.

Read more about:

• when Medicare compliance applies and who it applies to
• accessing Medicare and the PBS for health practitioners
• what we’re doing to support health practitioners comply with Medicare requirements
• the laws that govern Medicare.

For practitioners

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

• MBS item notes
• advice from AskMBS advisories
• MBS fact sheets
• MBS information material
• MBS education material.

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

• the CDBS guide
• CDBS information material
• CDBS education material.

Read more about how to substantiate CDBS services.

For prescribers

When prescribing PBS medicines, make sure you:

• are an authorised health practitioner
• prescribe as directed by PBS item notes
• understand PBS medicines restrictions
• understand PBS prescriber constraints
• read support material.

For dispensers

When dispensing PBS medicines, make sure you:

• are an authorised health practitioner
• understand and comply with PBS medicines dispensing requirements
• dispense in accordance with the edPBS dispensing requirements
• read support material.

For practice managers

If you receive Practice Incentive Payments, make sure you:

• complete the online training
• read the guidelines
• meet ongoing eligibility requirements.

Bill and claim accurately

You must bill, claim, prescribe and dispense MBS, CDBS and PBS items accurately to avoid compliance action, including claiming for practice incentives.

To understand your billing and claiming responsibilities:

• complete the relevant training
• see our overview information and case studies for Medicare billing in public hospital
• read Medicare claiming procedures for 
  • health professionals
  • pharmacists
  • dental practitioners
  • specialists
• see our Medicare billing assurance toolkit to identify, manage and prevent the risk of incorrect billing under Medicare
• ask for help from AskMBS email advice service
• see more resources.

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.

Read more about: 

• Medicare billing in public hospitals
• substantiating claims for diagnostic imaging and pathology services rendered to emergency department patients of public hospitals and claimed under Medicare.

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.

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.

Learn more

We provide educational resources and support to help you meet your legal obligations as a health practitioner and reduce the risk of incorrect billing under Medicare.