Billing accurately under Medicare

Information to help you understand your legal obligations when billing under the Medicare Benefits Schedule (MBS).

Page last updated: 02 July 2020

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What you need to know

Under the Health Insurance Act 1973 you're legally responsible for services billed to Medicare under your Medicare provider number or in your name.

You're responsible for incorrect claims regardless of who does the billing or receives the benefit. You will be responsible for the repayment of the full amount of the incorrect Medicare benefit that was paid.

The Department of Human Services only pay for services which are generally accepted by the relevant profession, as medically necessary for the appropriate treatment of a patient.
We're committed to making it easier for you to do the right thing. We aim to provide you with the right information and support you need to comply with the requirements of the MBS.

What you need to do

Be sure to check the services you provided against the services you have billed.
If you become aware of an incorrect payment and let us know voluntarily, you may avoid an administrative penalty.

Example
A health professional consults in a practice where 50% of the Medicare billings are paid to the practice to cover expenses. It is discovered that the practitioner incorrectly claimed item ABC, which had a benefit of $120, when the correct item was item XYZ, which had a benefit of $80. Even though the practice received half of the benefit, the health professional is responsible for paying back the full amount of the incorrect Medicare benefit that was paid, in this case $120.

Your provider number can't be used to claim services provided by other health professionals.
When you bill under Medicare, you must fulfil the requirements of the MBS. Visit MBS Online for the rules and item descriptors.

Refer to the legislation on which these requirements are based: Example
We identified that a neurologist had been inappropriately claiming Medicare benefits for diagnostic items she had not performed personally as per MBS guidelines. These services had been performed by the provider's neuro-physiology technician without supervision. A debt was raised for the value of benefits incorrectly claimed.

Detecting inappropriate practice or incorrect claiming

We have sophisticated ways of detecting possible inappropriate practice or incorrect claiming. These include:
    • monitoring and comparing the claiming profiles of health professionals to identify inconsistencies
    • identifying unusual patterns of item usage and item combinations
    • identifying and applying patterns learned from previous cases of non compliance
    • investigating tip offs
Example
Routine data monitoring identified a general practitioner claiming daily services at a rate significantly different to his peers. During an interview with our Medical Adviser under the Practitioner Review Program, it was found he was incorrectly claiming chronic disease management items when he had not met all item requirements, and that he was also incorrectly claiming general practice attendance items for services performed by the practice nurse. The practitioner had to repay the Medicare benefits he had received for all of the items incorrectly claimed under his name.

Consequences of non compliance

If you're audited and found to be non compliant, you:
    • will be responsible for the repayment of the full amount of the incorrect Medicare benefit that was paid, and
    • may be required to pay an administrative penalty
If you are reviewed under the Practitioner Review Program, you may be referred to the Director of Professional Services Review. As a result, you may be disqualified from claiming a Medicare benefit for a determined period.

Example
After analysing claims data, we identified an allied health professional whose billing pattern showed an unusually high level of servicing. When interviewed, the allied health professional admitted that they were unaware of the criteria for claiming services under Medicare. We determined the allied health professional had billed for services that were provided without the required referral. The allied health professional acknowledged the error and agreed to repay the benefits claimed.

If you are investigated and suspected of possible fraud against Medicare, you may be referred to the Commonwealth Director of Public Prosecution for consideration of criminal prosecution.

Resources

We have a number of resources that can help you stay up to date with the MBS and manage your claiming.
    • Health Professional Guidelines provide information about what documents you can use to substantiate services, if you're asked to participate in a health provider compliance audit
    • a range of online education materials relating to Medicare
Go to the Medicare Benefits Schedule to review the current schedule of item numbers and billing procedures.

Other resources

Useful links

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