Who must comply with Medicare obligations
Medicare compliance requirements apply to:
- healthcare organisations receiving PIP payments
- all health practitioners who bill, claim, dispense or prescribe under the
- medical doctors and specialists
- allied health providers
- dentists and dental practitioners
- nurses and midwives
- pharmacists, regardless of where they are providing the service.
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)
Compliance obligations are set by the:
- National Health (Pharmaceutical Benefits) Regulations 2017
- National Health (Listing of Pharmaceutical Benefits) Instrument 2012
- state and territory drug and poisons legislation.
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.