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  • Connect

    Issue 16

  • Business of medicine


    Common Medicare mistakes

    Dr Peter Henderson

    Dr Peter Henderson


    Deputy Chief Medical Officer and General Manager, Medical Advisory Services

    Medicare main image

    Medicare processed 433 million items1 in the last financial year, at a cost of $33 billion2. It’s therefore no surprise that compliance is a high priority for the Department of Health. Indiscretions or mistakes under Medicare can seem like a small issue, but can lead to penalties and disciplinary action, so it’s worth brushing up on the common issues.

    Changes to item numbers, terminology and descriptors make it challenging for doctors, with the COVID-19 vaccine items being the latest example. It’s the doctor who is responsible for getting it right when claiming Medicare Benefits Schedule (MBS) items. The Department of Health routinely monitors the claiming of MBS items and will contact a doctor if their claiming is irregular compared to their peers. Along with the 80/20 rule (a doctor cannot claim 80 or more professional attendance services for 20 days in any 12-month period), these are some of the common issues catching members out:

    1. Care plans with insufficient detail

    It is not uncommon to see care plans, such as Chronic Disease Management, that on the surface appear detailed and comprehensive, but do not satisfy the requirements of the MBS or are unacceptable to peers. Ensure all criteria specified for those items in the MBS are addressed in the medical record, and you are familiar with the relevant explanatory notes.

    2. Double claiming one appointment

    This can become an issue when claiming two attendance items for one appointment. When items are billed together, there may be a concern that specific requirements of each item, such as minimum consultation times, are not being met or there has been ‘double counting’. Claiming multiple items for one appointment is not a problem, so long as the requirements for each item have been met and there are not any other co-claiming restrictions.

    3. Claiming item numbers that are not clinically relevant

    To claim a Medicare benefit, the service needs to be ‘clinically relevant’. This means it would be generally accepted by your peers as being necessary for appropriate treatment of the patient. It is important to understand every MBS item number you use (including the descriptor and explanatory note), as you are responsible for applying them in a manner consistent with the law. Use your professional peer network to understand what is considered acceptable practice and whether your practice deviates from it.

    4. Staff claiming items on the doctor’s behalf

    The administration of Medicare services is often looked after by practice staff. This can be an efficient system and, when done properly, can help ensure you are meeting the item descriptors and you are billing appropriately. However, you are legally responsible for any consequences of inappropriate billing, so you must be satisfied that billings are being performed correctly. Ideally, you should sign off on all claims being made under your provider number.

    Public hospital outpatient clinics may also bill Medicare items on your behalf. Be aware of the details of this and obtain reassurance that the hospital will accept responsibility for any errors.

    5. Prescribing drugs of dependence

    The medical record should identify a clear clinical management plan for the patient’s underlying condition where drugs of dependence are prescribed. The record should include any authorities required for the prescribing of drugs and when they fall due for renewal.

    You can ask Medicare for guidance about an item number in a particular clinical circumstance and, if it is not forthcoming, ask Avant.

    If you have received correspondence from the Department of Health and are not sure what to do, seek Avant’s assistance. Acting on a request quickly can reduce the stress, length and severity of any compliance requirements.

    Useful resources

    Medicare: what you need to know:
    Avoiding the spotlight: Medicare review:
    Visit the Avant Learning Centre


    • 1. Services Australia, Medicare Statistics, July 2019-June 2020.
    • 2. Parliament of Australia, Budget Review 2019-20.


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