When Medicare compliance applies

Legislative requirements apply to health practitioners who bill, claim, dispense and prescribe under the Medicare Benefits Schedule, Child Dental Benefits Schedule and Pharmaceutical Benefits Scheme, and to organisations receiving Practitioner Incentives Program payments.

Who must comply with Medicare obligations

Medicare compliance requirements apply to:

This includes:

Medicare compliance requirements also apply to hospital treatment. Further information can be found on the Medicare billing in public hospitals webpage.

All health practitioners must meet eligibility requirements to access Medicare benefits before they can dispense, prescribe, bill or claim under Medicare programs.

Most health practitioners meet the requirements. When non-compliance occurs it's often accidental.

Programs and payments covered by Medicare compliance

Laws and agreements apply to the Medicare programs under which practitioners and organisations can bill, claim rebates, receive payments, and prescribe or dispense medicines.

Child Dental Benefits Schedule (CDBS)

The CDBS provides funding for basic dental services to eligible children in public and private settings. It does not cover orthodontic or cosmetic dental work, or services provided in a hospital.

The national Dental Benefits Act 2008 sets compliance obligations that dentists and dental practitioners must comply with under the CDBS.

Medicare Benefits Schedule (MBS)

The MBS lists services covered under Medicare. This includes treatment, consultation, allied health, pathology and diagnostic imaging services.

Medicare benefits are also available for some hospital treatments. To access Medicare benefits for hospital treatment, at a public or private hospital, a valid private election must be in place.

The national Health Insurance Act 1973 and associated regulations set MBS compliance obligations that health practitioners who provide MBS services must follow.

Read more about what the MBS covers.

Pharmaceutical Benefits Scheme (PBS)

The PBS Schedule lists the prescription medicines that are subsidised for eligible patients.

Compliance obligations are set by the:

Practice Incentive Program (PIP)

PIP encourages general practices to provide quality care, increase capacity and improve access and health outcomes for patients.

We may audit any activities relating to these programs as part of our compliance activities.

Date last updated:

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