Take a R.E.S.T. and stay out of trouble with Medicare

Take a R.E.S.T. and stay out of trouble with Medicare


Medicare investigates complaints made by patients, colleagues, or others relating to alleged misuse or incorrect use of the Medicare system. Additionally, all providers of Medicare services will routinely have their Medicare billing statistics examined for  variance from their professional peers and may be asked to explain any significant anomaly.

Diagnosis & treatmentFactsheets
14 / 04 / 2016
Compliance activities are common, monitoring is routine

The total cost of the Medicare scheme is over $18B per year1. Recent years have seen a significant increase in the resources allocated to ensuring that the Medicare scheme is not misused by patients, providers, or others. Medicare benefits are now being accessed for a wider range of services and in circumstances where they might not have been in the past. Recent emphasis by state health authorities to maximise the billing of private patients treated in public hospitals is one area that has generated many enquiries to Avant.

It is in the interests of members who are new to providing Medicare services that they understand their obligations as a provider of Medicare services and establish good billing practices. Those used to the Medicare system should keep abreast of changes to both the Medicare item numbers they use and the professional practices of their peers.

Medicare investigates complaints made by patients, colleagues, or others relating to alleged misuse or incorrect use of the Medicare system. Additionally, all providers of Medicare services will routinely have their Medicare billing statistics examined for variance from their professional peers and may be asked to explain any significant anomaly.

The computer algorithms used to analyse provider statistics are increasingly sophisticated. Ratios between services, combinations of services rendered on a single occasion or to a single patient and demographic information about the patient are analysed for statistical aberrance.

The consequences of the audit and review processes can be serious and include repayment of benefits, administrative and civil penalties, exclusion from the Medicare scheme, and even referral to AHPRA. It is worth noting that if a clinician is required to repay benefits, they are personally responsible for the full amount (irrespective of any percentage taken by a practice or hospital). Any repayment will not be covered by the Practitioner Insurance Indemnity Policy.

Taking a pro-active approach can avoid these serious outcomes:
  • Recognise your responsibility
  • Educate yourself and your employees
  • Stay in touch with your peers
  • Take action early when issues arise
Recognise your responsibility

It is self-evident that the responsibility for the correct use of Medicare items rests with the clinician under whose provider number the service is rendered.         

That fundamental feature of the Medicare scheme applies equally whether the service was rendered by a solo practitioner, an employed doctor, a staff specialist in a public hospital’s outpatient clinic, a specialist in private practice or any other circumstance.

Although the administration of Medicare claims may be delegated to support staff, the responsibility for ensuring claims are correctly made remains with the clinician and it will be to the clinician under whose provider number a claim was made that Medicare will look for any substantiation or, if the service is found to have been incorrectly claimed, repayment of benefit.    

Accordingly, it is the clinician’s duty to recognise their responsibility and take action to ensure they are in control of the claims made in their name.

Where the administrative staff is responsible for submitting claims to Medicare, doctors should require a daily print-out of the services being claimed against their provider number. A few minutes should be taken at the end of the day to check what is being claimed in your name and any errors corrected as soon as possible. Keep a copy of that document for your personal records.

Educate yourself and your employees

Doctors should know the elements of the Medicare Benefits Schedule (MBS) descriptors for the item numbers they use and any applicable explanatory notes. The up- to-date MBS can be readily accessed online and further advice  can  be  obtained  from  Medicare  or   from   Avant. See http://www.health.gov.au/mbs/search.cfm.

Administrative  staff  members  are  essential  to  the  efficientpractice of medicine but appropriate training must be provided as to when it is necessary to defer to the judgement of the doctor on item selection. Problems can arise where administrative staff members are given responsibility  for the selection of MBS item numbers which require medical knowledge for their selection and proper use.

For example, frequently-used professional consultation item numbers for GPs and some specialists have a time component – but time cannot be used as the sole basis for deciding the appropriate item number. Similarly, some procedural item numbers have complexities in their descriptions which may not be obvious to the non-clinician because, for example, they relate to the intra-operative or histopathological findings. Whether a wound repair involved suturing ‘deep’ tissue or whether an in-situ lesion was of a particular size are examples of matters which can only be determined by the clinician.    

Stay in touch with your peers

To be  eligible  for  the  payment  of  a  Medicare  benefit,  it  is a requirement that a service be ‘clinically relevant’. Clinical relevance means the service is generally accepted in the medical profession as being necessary for the appropriate treatment of the patient to whom it is rendered.

The criterion for Medicare’s audit and compliance activities and reviews by Professional Services Review is inappropriate practice. Inappropriate practice may be any conduct in connection with the rendering or initiation of services which would be unacceptable to the general body of your peers.

Such conduct may include:

‘Billing’ conduct

  • Using an incorrect item number or combination of item numbers;
  • Failing to fulfil the descriptor of the item number;
  • Billing Medicare for a service which is not eligible for a Medicare benefit (e.g. most cosmetic procedures, chelation therapy, tattoo removal, or gamma knife surgery);


  • Providing  unnecessary  or  excessive  services  (e.g.  where a patient routinely presents and a charge to Medicare is raised without there being a medical need);

‘Clinical’ conduct

  • Prescribing an inappropriate drug or dosage;
  • Failing to take an adequate history of the  patient’s presenting problem or to perform an adequate clinical examination;
  • Failing to address the underlying medical problem (e.g. prescribing pain relief without investigation and treatment of the cause of the pain);
  • Treating the patient in a way which would be unacceptable to the general body of peers (e.g. using out-dated or discredited techniques)

‘Medical Records issues’

  • Failing to make adequate and contemporaneous medical records (records which would allow another practitioner to take over the management of the patient);

Because all of those potential grounds of inappropriate practice relate to the acceptability to your peers of what you do in your practice, staying closely connected with your peer  group and keeping abreast of changing standards and practices is imperative. Discussing how you use MBS items with your peer group can ensure your practices remain consistent with the acceptable conduct of your peers.

Take action early when issues arise

Being audited by Medicare or having your services referred for review by Professional Services Review can be worrying and stressful. However it is important to remember that compliance activity is common. Furthermore, the mere fact that your practice (or an item number that you use) has been selected for audit or review does not mean you are doing anything incorrectly.

Moreover, even if errors have been made in your use of Medicare items or you are unsure whether you have mistakenly used an item number, action can be taken to resolve those issues and answer any questions.

Avant has much experience in assisting doctors with all sorts of Medicare issues. The earlier a problem can be addressed the better  the  outcome  so  please  contact  Avant  promptly if you are requested to complete an audit or have your practice reviewed.

DISCLAIMER: This topic is not comprehensive and does not constitute legal advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.

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1 1. http://www.health.gov.au/internet/budget/publishing.nsf/Content/2013-2014_Health_PBS/$File/2013-14_DoHA_PBS_1.04_Strategic_Direction_Statement.pdf.