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.
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.
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:
- 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:
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 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:
- complete 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 and 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.
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.
Further information can be found on the Medicare billing in public hospitals webpage.
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:
- proactive education and training activities
- routine monitoring and data matching of health practitioners’ data
- Practitioner Review Program reviews
- referrals to the Professional Services Review
- fraud investigations.
Read more about what we’re doing to help you comply with your Medicare obligations.