Services Australia has a range of educational material for health professionals about Medicare available at:

• • Medicare Benefits Schedule (MBS) - Medicare for Health Professionals - Health Professional Education Resources (servicesaustralia.gov.au)
• • Health professionals starting with Medicare - Health professionals - Services Australia

In summary, to be eligible for payment of a Medicare benefit the service is required to be ‘clinically relevant’ and medically necessary. Generally, this means the service is accepted by your peers as being necessary for the appropriate treatment of the patient.

It is also important to remember that a practitioner is personally responsible for all item numbers that are billed under their provider number. Work with your practice manager to set up a system to regularly review items that have been billed under your provider number and ensure you understand the full item descriptor and the explanatory notes that are relevant to each item you are billing.

Regularly review MBS Online (MBS Online - MBS Online) to ensure you stay up to date with the requirements. Use the knowledge of more experienced peers to advise you on best practice. However, do not rely on ‘corridor advice’ or hearsay from colleagues as a substitute for your own knowledge and understanding. If you are unsure about any aspect of billing for Medicare services, seek clarification from the Department of Health askMBS@health.gov.au or discuss with Avant.

Links:

Health professionals starting with Medicare - Health professionals - Services Australia

Medicare Benefits Schedule (MBS) - Medicare for Health Professionals - Health Professional Education Resources (servicesaustralia.gov.au)

Recognition for Medicare benefits - Medicare benefits for health professionals - Health professionals - Services Australia

Recognition as a general practitioner to provide Medicare services - Medicare benefits for health professionals - Services Australia

MBSM38-Medicare billing and claiming–basics (servicesaustralia.gov.au)

Health Professional Education Resources (servicesaustralia.gov.au)

The request for a statutory declaration is likely to relate to an exemption under section 19AB of the Health Insurance Act 1973 which allows a doctor to work in a Distribution Priority Area (DPA – for GPs) or District of Workforce Shortage (DWS – for other specialists). Practices sometimes ask medical practitioners to sign a statutory declaration saying they are no longer working at the practice and that they will not work within the same local government area to allow the practice to replace the DWS doctor position after the practitioner leaves. You do not have a legal obligation to sign a statutory declaration unless such an obligation exists in your written contract. You should seek advice from Avant before signing any statutory declaration because it may affect future employment offers you receive.

Links:

What is a Replacement District of Workforce Shortage (DWS) and How Do I Get One? - People Medical Consulting

Health Workforce Locator | Australian Government Department of Health and Aged Care

When you make a Medicare claim for a service (bulk-billed or otherwise), it is a legal requirement that you maintain an adequate and contemporaneous medical record of the service. To be adequate, the record needs to:

• • clearly identify the name of the patient
• • contain a seperate entry for each attendance by your patient for a service and the date the service was rendered or initiated
• • provide clinical information adequate to explain the type of service rendered or initiated at each attendance
• • be sufficiently comprehensible so that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care.

To be contemporaneous the record must be completed at the time the service was rendered or initiated or as soon as practicable afterwards.

If you use macros or templates, review these regularly to ensure information that is automatically recorded is appropriate for the particular patient. Specifically, you need to remove any information from the automatically recorded template if it does not apply to your patient. If it is inadvertently left in the medical record it may be argued that the entry was automatically generated and that the other elements of the attendance were not met. Be vigilant in reviewing entries for auto-fill templates because they are commonly criticised by Medicare regulators. The level of documentation required by Medicare is the same as your obligations under the Medical Board’s Good medical practice: a code of conduct, which says another doctor should be able to tell what went on in the consultation when they read your notes.

Your medical records are not just a reminder for you. Medical records are a scientific record of the patient’s care and a billing record that is legally mandated. Good records will also provide you with the best chance of a good outcome if you are reviewed or audited.

It is important that the clinical record reflects what occurred during a consultation and provides evidence that the claimed item number was appropriate. The record is expected to contain information such as history, investigation, a management plan and/or preventative health care to a sufficient degree that makes it clear the consultation would have taken the duration that is required for any time-based Medicare item numbers. For example, a simple “script written” with no other detail would not generally be enough to show a peer that a consultation took six minutes.

If you feel that an MBS item number is outdated you should make an enquiry with askMBS (MBS Online - AskMBS Email Advice Service) and request a written response in relation to the current requirements for the item number.

Links:

Avant - Pressure points - Medicare compliance

Administrative record keeping guidelines for health professionals | Australian Government Department of Health and Aged Care

If you are undertaking a locum placement at a particular location for two weeks or more, or if you intend to do a recurring locum placement at the same location for less than two weeks on a regular basis, you should apply for a provider number for that location.

If you are undertaking a locum placement for less than two weeks at the location and do not anticipate returning to the location, you should contact the Department of Human Services to check if you should obtain a provider number for the locum tenens not specific to the location.

If you are relieving a specialist but do not hold specialist registration you cannot claim Medicare benefits at the rate for a specialist. You should refer to MBS Online to review the explanatory memorandum that applies to your circumstances.

Links:

Note GN.2.6 | Medicare Benefits Schedule (health.gov.au)

Private billing procedures for health professionals - Health professionals - Services Australia

Note GN.6.16 | Medicare Benefits Schedule (health.gov.au)

Yes, you can have the consultation with the patient. However, without a valid referral you won’t be able to access Medicare benefits for that consultation.

The patient’s treating health practitioner should have a consultation with the patient to establish the need for the specialist’s involvement before the specialist is engaged.

A GP cannot backdate a referral after the patient has been seen. Back dating a referral is fraud. The Health Insurance Act makes it an offence to offer a false statement relating to Medicare benefits.

If a referral was made but has been lost, stolen or destroyed, the specialist can note “lost referral” for the initial attendance and Medicare benefits can be claimed. However, a replacement referral or letter will be required to claim Medicare benefits for any subsequent attendances with the specialist. Similarly, the word ‘emergency’ must be included on the claim where that is relevant. In either case, only one consultation without a written referral can be rendered before a formal referral is obtained.

A GP who is coordinating the development of TCAs must consult with at least two collaborating providers who will provide a different type of treatment or service.

Avant frequently assists members who have come to the attention of Medicare for not engaging in adequate collaboration with the other providers.

The patient must be discussed with each of the collaborating providers. The discussion must be two-way and preferably verbal. If a verbal discussion is impractical, it may be in writing. However, it still needs to show a discussion has taken place.

Each collaborating provider must contribute to the development of the TCA. They must include advice on the treatment they will provide to the patient based on their understanding of the patient’s needs.

Each collaborating provider must have agreed to provide treatment and services to the patient under the TCA.

Every discussion with collaborating providers should be documented, including the advice they have provided about their treatment and services.

The requirements for collaboration are not met by:

• • sending a referral letter to a provider with no other communication
• • receiving a letter from a provider after they have provided treatment or services
• • an agreement from a provider to first assess a patient and then advise on what treatment they will provide. They must provide advice at the time of collaboration, before starting treatment, under the TCA
• • “standing orders” where a provider will agree to do the same service on all patients referred to them.

In practice, it is generally necessary for two GP attendances to satisfy the collaboration requirements of 723. The initial attendance will be for the GP to identify that a patient will benefit from a TCA, to discuss the steps involved in preparing the TCA and to record their agreement to have the TCA. The GP will then collaborate with the other providers. The second attendance will be to complete the preparation of the TCA and to discuss its contents with the patient.

The other requirements needed to satisfy this item number are at Note AN.0.47 | Medicare Benefits Schedule (health.gov.au)

MBS Online states that an after-hours consultation is ‘urgent’ if the medical practitioner first determines that the patient requires urgent medical assessment. It states that when considering the need for an urgent assessment of a patient’s condition, the practitioner may rely on information conveyed by the patient or patient’s carer, other health professionals or emergency services personnel. A record of the assessment must be completed and included in the patient’s medical record.

The MBS urgent after-hours items may be used when, on the information available to the medical practitioner, the patient’s condition requires urgent medical assessment during the after-hours period to prevent deterioration or potential deterioration in their health. Specifically, the patient’s assessment:

• • cannot be delayed until the next in-hours period; and
• • the medical practitioner must attend the patient at the patient’s location or reopen the practice rooms. (Note AN.0.19 | Medicare Benefits Schedule (health.gov.au)

It is important to document the reasons why you consider the assessment to be urgent in the medical record. This might reflect factors to show any risks associated with delaying the assessment.

Links:

Note AN.0.19 | Medicare Benefits Schedule (health.gov.au)

There are two part to this:

• • The 80/20 rule relates to services not attendances. If you provide 80 or more services on 20 or more days in a 12 months period, it will be automatically deemed “inappropriate practice” and referred to the director of Professional Services Review (PSR).
• • When you provide slightly less than 80 services in a day, Medicare may still have concerns that the quality of care you provide is inadequate. Avant has seen cases where Medicare raised concerns about doctors who provided 60 or more daily services for a prolonged period. This pattern of billing is likely to come to the attention of the Practitioner Review Program, which may require you to undergo an interview with them.

Additionally, the 30/20 rule applies specifically to telephone consultations billed to Medicare. If you provide 30 or more telephone consultations per day on 20 or more days in a 12 month period, it will be automatically deemed “inappropriate practice and referred to the director of PSR.

Further information: Prescribed Pattern of Service – The 80/20 rule | Australian Government Department of Health and Aged Care

MBS Online - MBS Telehealth Services from January 2022

No.

The Department of Health has advised that both the patient and health service provider must be physically located in Australia.

They have also flagged that data matching laws allow them to cross check immigration records of both patients and doctors.

Yes. For a personal attendance, only the time spent face-to-face with the patient can be claimed in relation to a time-dependent Medicare benefit. For telehealth consultations, only the time the patient is on the telephone or video call can be counted towards the minimum time component for a time-dependent Medicare item number.

Only the time spent dealing with the patient’s health condition, which the MBS says is the time the patient receives “active attention”, can be counted towards a minimum time requirement. There may be cases when the time required for a particular patient is not evident from the clinical complexity of the patient’s health condition, such as if the patient requires more time because they have an impairment or require an interpreter to communicate. The time required to treat the patient can be claimed if the patient’s circumstances add to the clinical complexity, as long as the records reflect the reason why more time was required.

If you are still unsure after reading the description and explanatory memoranda for the relevant item number you can email medicare.prov@services.australia.gov.au or askMBS@health.gov.au to obtain written clarification from the MBS. The MBS website also has a range of factsheets that may assist (MBS Online - Current Factsheets).

Fulfilling your obligation to the MBS is not only about billing the correct item numbers but also requires you to understand and comply with all aspects of appropriate practice. You should therefore ask experienced peers about their practices in relation to the item number.

Links:

AskMBS email advice service | Australian Government Department of Health and Aged Care

Avant - Medicare: what you need to know

Avant - Medicare compliance

News for Health professionals - Services Australia

MBS Online - MBS Online

AskMBS Advisories | Australian Government Department of Health and Aged Care

MBSM38-Medicare billing and claiming–basics (servicesaustralia.gov.au)

Essentially, if a practitioner bulk bills for a service, this means that they agree to accept the Medicare benefit as full payment for that service. Nothing else (bandages, extra booking fees, etc) can be charged for that service. The one exception is when a patient is provided with a vaccine from the practitioner’s own supply held at the practice. This is only for general practitioners and other non-specialist practitioners for certain item numbers listed in the explanatory note, and only for vaccines not available for free through federal or state funding.

Links:

Note GN.7.17 | Medicare Benefits Schedule (health.gov.au)

The starting point is that a public patient in a public hospital should be treated free of charge if the patient has a current Medicare card and the treatment is clinically necessary. It is possible to also bill Medicare if your patient elects to be treated as a private patient in a public hospital (and they are Medicare eligible).

There are some basic requirements:

• • The patient must give their informed financial consent and their agreement to be treated privately must be in writing.
• • Patients must have a choice of doctor.
• • Doctors treating the patient as a private patient need to have private practice rights (as is the case with VMOs), must not be doubly paid for the service (must provide services other than in the course of their employment) and must follow the requirements for billing Medicare set out in the MBS as all doctors billing Medicare must do.

Links:

Avant factsheet - Medicare compliance

No.

The Health Insurance Act 1973 (Cth), which is the legislation that outlines the system under which Medicare payments are made, defines a “professional service” for which a Medicare benefit can be claimed as a clinically relevant service, other than a diagnostic imaging service, that is rendered by or on behalf of a medical practitioner.

It also states, as do the MBS explanatory notes, that to claim a benefit from Medicare the medical practitioner must personally attend the patient before a "consultation" is regarded as a professional attendance.

This applies to children as well as residents in aged care facilities.

It also includes telehealth. The requirement that the patient is present is the same whether the consultation is face-to-face, by video or by telephone.

MBS Online clearly states that telephone attendances or any situation where the patient is not in attendance will not attract a Medicare benefit (AN 0.5).

Subject to any specific restrictions, you may bill more than one MBS item for a patient on a single occasion provided each item is medically necessary for the appropriate treatment of the patient and all necessary elements of each service are met. There are many specific restrictions that apply to particular items or groups of items in the MBS, including where one service is rendered ‘in association with’ another and the item descriptor includes a phrase such as “where no other procedure is performed”, “not being a service associated with a service to which XYZ item applies” and several others. It is, therefore, always important to have carefully read the full item descriptor and any applicable explanatory notes for the services you bill by searching MBS Online. Another example would be when a chronic disease management plan item is billed, another consultation item cannot also be billed.

You cannot bill multiple items to different patients at the same time, for example, where a family attends a consultation.

There are some general principles that provide a framework for understanding what can or can’t be billed.

A foundational principle is the ‘complete medical service’ principle, which means that each Medicare service must fully meet all elements of the MBS item on its own. For example, if a major surgery involves several procedures that could otherwise be billed as individual procedures but which are part and parcel of the major surgery, only the major surgical item can be billed. Conversely, if each necessary procedure can ‘stand on its own’ and each descriptor is fully met, each can billed.

The Services Australia website provides information on common reasons why claims are rejected (Education guide - Medicare reason codes and reducing claim rejections - Health professionals - Services Australia). Error codes are provided to show the reasons why Medicare claims are rejected (Medicare digital claiming return codes - Medicare Easyclaim - Services Australia). Claims may be rejected because of an issue with how the claim was submitted (return codes are used), or because of an issue with the information submitted (reason codes are used, for example, incorrect Medicare item number). If you review the code provided and still require further information you can call Medicare Health Professional Online Services (HPOS) on 132 150 and select option 6 (Electronic Claiming including Online Claiming), or the eBusiness Service Centre on 1800 700 199 and select option 3 (Electronic Claiming including Online Claiming).

Links:

Education guide - Medicare reason codes and reducing claim rejections - Health professionals - Services Australia

Yes, you do. Regardless of who processes the amount claimed under a provider number, if there is any question about an amount to be recovered by Medicare the primary debtor will always be the doctor whose provider number is used to make the claim.

If you have a provider number and are rendering services you are a part of this system and you will be considered responsible for all services you claim. This applies regardless of the circumstances in which the services are rendered, whether they are bulk-billed or not, whether provided in a hospital or practice context, and regardless of the extent of your involvement in checking or submitting the claims to Medicare.

Even if your employer says they will indemnify you for billing errors, if your MBS billing practice is found to be inappropriate or incorrect (except when a shared debt determination is made by the Department of Health), you will be responsible for any penalties or repayments. Accordingly, it is in your interest to maintain tight control over your provider number and what is being billed under it.

If you do have to pay penalties or repayments to Medicare, reimbursement from your employer would be a separate matter between you and your employer. There is no guarantee that an employer would reimburse for any payments required to be made by Medicare, even if there is an agreement to indemnify.

One penalty for incorrect billing of item numbers can be a period where you are not allowed to bill those item numbers. It is unlikely any employer indemnity would include compensation to you for that time.

In many practices the administration of Medicare services is generally looked after by staff rather than by the doctor providing the service. This can be a convenient and efficient system that, when done properly, can assist to ensure you meet the item descriptors and are billing appropriately.

However, as the consequences rest with you, you must be satisfied that billings are being performed correctly. Ideally, you should sign off on all claims being made under your provider number before the claim is submitted, and you should retain a copy of all claims made.

Read the letter carefully and determine what the letter is asking you to do.

Once you have done this, you should complete an incident notification form, which can be found on the Avant website under the tab ‘Tell us about an incident’. You should email the completed form with all the correspondence you received from Medicare/Department of Health to nca@avant.org.au. We can then assist you to understand what the next steps will be.

Letters from Medicare/Department of Health come in different formats requesting a variety of responses.

If the letter notifies you that your practice with a particular item number is different to that of your peers (for example, you may use it more often), you do not necessarily need to do anything other than be aware and think about what you do and why. You should have clinical reasons and medical records to substantiate every item number that you bill.

Some letters do require you to “review and act now”. It may identify that you have been billing outside the norm and ask you for an explanation. The letter may come with a schedule (list) of your billings that you are required to review. You might then consider making a ‘voluntary acknowledgment of incorrect payments’ if any claims do not meet the criteria in the checklist.

Alternatively you may receive a letter informing you that you need to attend an interview as part of the Practitioner Review Program. This letter will inform of you of the time, date and venue of your interview and will identify the concerns that you will be required address in the interview.

You should contact Avant if you are asked to “review and act now” or attend an interview.

The Department of Health often uses data analytics to identify and target compliance activities. It compares practitioners to one another to identify outliers. However, before it gathers more information about you, the Department is rarely aware of the specific characteristics of your practice.

The vast majority of doctors bill correctly. If you have received a letter from the Department of Health it does not automatically mean that you have billed incorrectly or that you will have to pay money back.

The Department of Health conducts a number of compliance activities and specific letters will be sent in accordance with those. Some of those activities include:

• 1. Targeted campaigns - where possible non-compliance is identified. You may inadvertently not comply with the descriptors of MBS item numbers. The department systematically reviews claims made for MBS and associated incentive items. It will decide to send letters to doctors it suspects may be using particular item numbers incorrectly and/or if the patient/consultation is not in accordance with the eligibility criteria. A high number of billings of a particular item number, compared to your peers, may also trigger a letter from the Department of Health.
• 2. Professional review if there is the potential of inappropriate practice. The Department reviews the items that you charge for and the degree of variance from others in your specialty. The Department may decide to include you in the Practitioner Review Program if it is concerned that the reason for the variance is because of a lack of clinical indication.
• 3. Suspected fraudulent activity.

Remember, you may be doing everything right but because of the circumstances of your practice or the clinical areas that you focus on, you may sit outside of the normal range for a particular item number.

The Department of Health has sophisticated methods to detect when doctors may have claimed a benefit incorrectly. Some of these include:

• • comparing the claiming behaviours and patterns of doctors to identify inconsistencies between peers
• • identifying remarkably high patterns of item usage and or unusual item combinations
• • detecting patterns learned from previous cases of incorrect claiming
• • investigating tip offs.

Avant has three key recommendations to minimise the risk of compliance action from Medicare.

1. 1. Avoid professional isolation

Stay in touch with your peers – talk to them about the way you bill Medicare. In Medicare compliance, ‘inappropriate practice’ can be established if any aspect of your conduct in relation to Medicare services is deemed unacceptable to your peers. This may include the adequacy of your medical records, the level of services rendered or the appropriateness of prescriptions. Practising in a manner that is different from your peers is not necessarily inappropriate. However, your capacity to know and consciously employ the distinction is only valid if you understand what common practice is and how you are deviating from it.

It is, therefore, essential that you keep up to date with your clinical knowledge and your peer network. Practising in isolation from your peers can lead to a host of clinical and medico-legal issues, including variance in Medicare services that may attract scrutiny or criticism.

If you hear or think of ways to increase your Medicare billings that are not consistent with what your peers are doing, it is unlikely that Medicare will consider that billing as appropriate.

1. 2. Ensure that you keep up to date with the Medicare billing rules

Regularly check MBS Online (MBS Online - MBS Online) to stay up to date with the full item description for all Medicare item numbers that you bill, as well as the relevant explanatory notes.

1. 3. Maintain control of your billings

By doing this you can be sure that you consider any medical service billed under your provider number is clinically relevant and medically necessary. Be careful not to rely too heavily on the practice support staff to make decisions about which item numbers to bill. All instructions to bill MBS items should be communicated in writing by you to the practice staff. No MBS item numbers should be invoiced to Medicare unless instructed in writing by you as the holder of the provider number.

At the end of each working day request a list of all item numbers billed so you can keep track of your Medicare billings. You should retain these documents for your records.

Links:

Avant - Podcast: It happened to me: Medicare compliance letter

Avant - Pressure points - Medicare compliance

An audit is an evidence-based assessment that determines whether all the elements required for a particular benefit have been met. The Department of Health conducts audits for the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS), Child Dental Benefits Schedule and Incentives Program.

Audits do not review the clinical appropriateness of your treatment decisions.

Generally, you will be sent a letter that will explain the audit. You should send all of the correspondence to Avant so we can assist you. Please send it to nca@avant.org.au.

It is likely that you will be notified of a concern and asked to produce documentation that supports your charging of a particular MBS item number. This is known as a ‘Notice to Produce’.

The Notice to Produce will explain the department’s concern, details of the benefit or service that needs to be substantiated and the type of information that will help substantiate those services. That information will likely be in your medical records.

If your documentation does not confirm that all elements required for a particular item number have been met, then you may be required to pay back funds to Medicare.

Make sure you are clear about what the Department of Health is asking you to do. If you remain unsure you should contact the Department to discuss. If the list of files you are asked to review is extremely long it may be possible to start with a random selection of files to determine if there is a trend or an obvious reason for the Department’s concern that you can respond to without the need to review all the files on the schedule.

You should send all of the correspondence to Avant so we can assist you. Please send it to nca@avant.org.au.

In the first instance, you should contact Avant for advice. If you have any correspondence from the Department of Health you should send it to Avant so we can assist you. Please send it to nca@avant.org.au.

You will need to notify the Department of Health as soon as possible if you notice any errors in what you have claimed from the MBS or other benefit schemes. You can do this by filling out a voluntary acknowledgment of incorrect payments form.

After you have completed this form, the Department of Health will contact you to confirm the amount that you will need to repay.

If you have any correspondence from the Department of Health you should send it to Avant so we can assist you. Please send it to nca@avant.org.au.

Do not ignore it. Being proactive by informing the Department of Health will place you in the best position to manage the situation.

A voluntary acknowledgment is when you let the Department of Health know that you have claimed a benefit incorrectly. You can do this by completing a voluntary acknowledgment of incorrect payments form and submitting it to the Department.

If you have claimed a benefit incorrectly you will need to repay the money to the Department. Depending on the amount you owe, an administrative penalty may also apply. In some cases, a voluntary acknowledgement can help reduce that administrative penalty.

For more information on voluntary acknowledgments visit the Department of Health website.

The type of information that the Department of Health will require will depend on the type of claim that needs to be substantiated. You do not have to provide the entire file of a patient and you can censor information or provide excerpts. The Department of Health has prepared the Health Professional Guidelines to help you understand what documents can be used to substantiate the services being audited.

Any personal information about your patients collected during an audit is kept securely by the Department of Health.

The Australian Privacy Principles in the Privacy Act 1988 allows you to give this type of information to the Department of Health for the purposes of an audit.

No. You are not required to notify your patients.

You will know of the outcome of the audit before you owe money to the Department of Health. If you disagree with the outcome you can submit an application to review the decision.

If you do not provide the documents relating to the claims being audited you may be subject to a civil penalty, which is similar to a fine.

You can find more information about Medicare audits on the Department of Health website.

The Practitioner Review Program (PRP) monitors Medicare data to identify and examine variations that may indicate you have engaged in inappropriate practice. The variations examined are those that demonstrate you are practising in a way that is statistically and significantly different from your peers.

The Department of Health considers Medicare data, which are made up of the claims you make to Medicare and PBS prescribing data.

Simply, it means any aspect of your conduct in connection with you providing or initiating services that would be unacceptable to your peers.

The meaning of inappropriate practice is found in legislation: Health Insurance Act 1973, section 82.

Generally, it relates to:

• • a doctor providing or initiating Medicare services or prescribing or dispensing PBS medicines in a way that would be considered unacceptable to the general body of the doctor’s peers
• • the 80/20 rule. This means that a doctor has rendered or initiated 80 or more professional attendance services on each of 20 or more days in a 12-month period. For more information on this rule, please visit the Department of Health website.

The Director of the Professional Services Review will consider whether:

• • the service you provided met the requirements of the MBS or PBS item descriptor, including the clinical and medical relevance of the service
• • you kept adequate and contemporaneous records for the Medicare or PBS services that you provided or initiated. These requirements can be found in the Health Insurance (Professional Services Review) Regulations, and include:
  • - the record includes the patient’s name
  • - the record contains a separate entry for each attendance by the patient for a service
  • - each separate entry includes the date on which the service was rendered or initiated, provides sufficient clinical information to explain the service, and is completed at the time or as soon as practicable after the service was provided or initiated
  • - the record is sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record
• • your services contravened the 80/20 rule.

There are five stages of the Practitioner Review Program:

• 1. Initial contact – The Department of Health will contact you and let you know about its concerns. It will then write to you listing the concerns, the relevant Medicare servicing data and an invitation to attend an interview.
  
  When you have received written notification you should contact Avant for advice. Please send all correspondence that you have received from the Department of Health to us at nca@avant.org.au.
• 
  2. Interview - This is an opportunity to talk more about your practice and the anomalies with your billings. Before this stage, the Department of Health does not know specifics about your practice or the patients you treat. The data it has are simply statistical. There is no set format to this interview. The Medical Adviser from the Department will often come to a location that is convenient to you, such as your practice, or sometimes this can be conducted over the phone. You can bring a support person to this interview.
• 
  3. Post interview - The Department of Health will consider what you have told it and then advise you of the outcome. It is possible that if you address all its concerns in the interview that no further action will be taken. If not, you will be reviewed (see stage 4) or be referred to a delegate of the Chief Executive Medicare (see stage 5).
  
  The Department will send you details of the outcome in a letter. You should send this letter to your Claims Manager at Avant.
• 
  4. Review - The Department of Health could decide to review your billings and practices for another period of time, usually six months. After this review period, all concerns may be addressed and no further action will be taken. Alternatively, some concerns may remain or new concerns could be identified. If this is the case the matter will be referred to the Chief Executive Medicare who will consider making a request to the Director of Professional Services Review for consideration of an inappropriate practice finding.
  
  The Department will send you details of the outcome of the review in a letter. You should send this letter to your Claims Manager at Avant.
• 
  5. Delegate assessment - Delegates (health professional advisers and senior staff) of the Department of Health will review all the information they have at this stage. If they no longer have concerns they will close your matter.
  
  If concerns still exist, a letter will be sent to you by the delegates inviting you to make a written submission to provide further information. You should send this letter to your Claims Manager at Avant and they will able to assist you. If the delegates are satisfied after reviewing the further information, they will close your matter.
  
  If the delegates are not satisfied, they will make a request to the Director of the Professional Services Review to review your provision of services during a specified period. While this is the last step of the Practitioner Review Program (PRP), it is the first step of the Professional Services Review (PSR). The PSR is an independent authority and any further contact about your matter will be directly between you and the PSR.

The possible outcomes of the PRP are:

• 1. No further action will be taken if the Medical Advisers (doctors employed by Department of Health) no longer have concerns after meeting with you or after you provide them with extra information.
• 2. A review of your Medicare data will take place after six months if concerns still exist.
• 3. Referral to the Professional Services Review if you progress through all stages of the PRP and concerns still exist.

You can find more information about the Practitioner Review Program on the Department of Health website.

If you have been referred to the PSR we recommend you:

• 1. Contact your medical defence organisation immediately to seek assistance. If you are an Avant member, contact your Claims Manager or send an email with the PSR correspondence to nca@avant.org.au.
• 2. Familiarise yourself with the documents that the Chief Executive Medicare has sent you, including concerns and statistics about your practice. You should also familiarise yourself with the item descriptors that match the Department’s concerns. These item descriptions can be found at MBS online.

Consider informing people close to you that you have been referred to the PSR. This is your choice but can be beneficial to your wellbeing.

For more information about the process please visit the PSR website.

The process begins at the last stage of the Practitioner Review Program (read above). If delegates (health professional advisers and senior staff) of the Department of Health request the Director of the Professional Services Review to review your provision of services, the Director will consider the information and material. If it appears that you engaged in inappropriate practice the Director will conduct a review.

To do this the Director will acquire a random sample of the services that you billed and will ask for the corresponding medical records. The Director will review these and prepare a report. Before completing the report, the Director may meet with you to discuss the billings and records.

When you receive this report you will have the opportunity to make submissions. We can assist you with this part of the process.

At this stage, the Director has a few options. These include:

• • that no further action is required
• • to enter an agreement with you in which you must acknowledge you engaged in inappropriate practice and likely repay money relating to the services. The Director can also disqualify you from billing to Medicare for a specified period
• • refer you to a committee of your peers for a hearing to decide if you engaged in inappropriate practice. For more information on the Review by a Committee please visit this website.

If the Director of the PSR is concerned that you have not complied with professional standards or that you have caused risk to somebody’s health, a referral can be made to AHPRA or another regulatory body.

The Shared Debt Recovery Scheme is a way the Department of Health can share a debt that it is owed following a compliance audit. This means that rather than the doctor being responsible for all the debt that is owed to the Department of Health, the debt can be shared between the doctor (the ‘primary debtor’) and another person or organisation (the ‘secondary debtor’) in certain circumstances.

The primary debtor will always be the doctor whose provider number is used to claim from Medicare.

The secondary debtor will most likely employ or engage the primary debtor. However, it could be any relationship between the two that relates to claiming from the Medicare Benefits Scheme.

You will receive a letter from Medicare identifying concerns with your practice.

At this stage the letter may invite you to provide further information regarding a possible secondary debtor. The Department will review that information and determine if it will notify the secondary debtor.

You, as the primary debtor, and the secondary debtors will each have an opportunity to make submissions on whether the debt should be shared and, if so, the percentage that each debtor should owe.

The Department may then make a share debt determination.

A secondary debtor will not exist in all cases. For this to happen there must be a relationship between you and the secondary debtor (ie, employment, engagement or another arrangement related to the charging of Medicare).

Issues the Department will consider include:

• • if the secondary debtor controlled or influenced the making of the false or misleading claim. For example, the practice that employs you predetermines item numbers that are charged for certain services before a consultation
• • if the secondary debtor received a financial benefit as a result of the false or misleading claim. For example, the practice may have received a percentage of the billings you charged.

The Shared Debt Recovery Scheme applies to Medicare compliance audits that occur after you have received payments from Medicare for the care provided.

The Shared Debt Recovery Scheme will not apply:

• • to claims adjustments that occur routinely as part of health practice, where you alert the Department to an error to correct the claims record
• • if you make a voluntary acknowledgement of incorrect payments such as after receiving a letter asking you to review your billings or following a targeted campaign (where Medicare has sent you a letter highlighting an anomaly in your practice)
• • to debts resulting from inappropriate practice following referral to the Professional Services Review
• • to debts resulting from a false or misleading statement that can be shown to have been made by someone other than the practitioner
• • to debts arising where one party has, without the knowledge of the other, engaged in criminal conduct (fraud) in relation to Medicare claims or billing.

Under the regulations, the default position is that the primary debtor will pay 65% of the debt and the secondary debtor will pay 35% of the debt.

However, the Department of Health can consider any arrangements that were in place between the parties and what influence or control the secondary debtor may have had over the billing of services when determining the final proportion and amount owed by each party.

If you are the subject of a Medicare audit you will receive a letter containing a request for documents. The letter will clearly identify if the Shared Debt Recovery Scheme could apply in relation to that audit.

No. The Shared Debt Recovery Scheme is not intended to make receptionists or administrative staff responsible for debts from services billed on behalf of a doctor. However, the practice may be liable as a secondary debtor.

Any person found to have billed Medicare services against your provider number without your knowledge may be held responsible for the entirety of any Medicare debt and criminal prosecution may be pursued.

The Department of Health is not bound to any terms in a contract between parties. It will make the debt determination using the criteria above. The Department has legislative authority to recover the debt. If there is a contract in place between the two debtors, the department may still apply the Shared Debt Recovery Scheme.

The Scheme began on 1 July 2019. It only applies to audits that started from that date but can still apply to billings from 1 July 2018.