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INSIGHTS: Health professionals: Are you complying with your obligations?

December 2, 2013


The Department of Human Services has released its Compliance Program for the next two financial years (2013–2015), setting out its proposed strategies for assisting recipients, health professionals and businesses to comply with their obligations when receiving services or payments.

This information is important for many health professionals, who deal with the Department on a regular basis through the claim of Medicare benefits or incentives, or by prescribing or dispensing medication that is listed on the pharmaceutical benefits scheme.

The Department has highlighted the following factors relevant to its audit activities:

  • The focus is on ensuring that health professionals are educated about their obligations, as it believes that the majority of people wish to be compliant. The Department website provides eLearning Programs, handbooks, quick reference sheets and other reference material. Much of the material is specially designed for new health professionals, so they can become familiar with their obligations for working with the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. It is stated that the Department will work with the peak bodies of allied health professionals to better communicate and educate allied health professionals of their obligations.
  • The Department will continue to implement a program of data analysis, to monitor health professionals’ claiming patterns and other compliance requirements. This will include the cross-checking of information between different departments, and examination of whether a health professional’s pattern of Medicare claiming deviates substantially from the claiming patterns of their peers. Payments of bulk bill incentive items will be examined by the Department, to ensure that the billings were made for eligible patients.
  • Where there is a risk that Medicare payments have been incorrectly made, the Department will conduct compliance audits to investigate. If a health professional is suspected of inappropriate billing practices, such as providing services that are not clinically necessary, such as prescribing high levels of medicines of potential addiction, or ordering too many tests, the Department may appoint a medical advisor to conduct a review. The Department will seek to recover from practitioners any money that has been incorrectly paid, and in the event there has been suspected fraudulent behaviour, report the matter for criminal investigation. Health professionals who are subject to investigations or review will be given an opportunity to respond to concerns raised by the Department.
  • Under the Health Insurance Act 1973 (Cth), a health professional is deemed to have acted inappropriately if they have provided 80 or more professional attendances on 20 or more days in a 12 month period. The Department will endeavour to contact and warn health professionals who are identified as approaching this threshold.
  • The Department will continue to perform audits of professional billings of Telehealth services—a program which delivers health services through telecommunication technology, such as video consultations.
  • Payments to pharmacists under the Fifth Community Pharmacy Agreement will be monitored by the Department, to ensure they are properly made. A particular focus will continue to be on Residential Management Reviews, Home Medicine Reviews and the payment processes for pharmacy practice incentives. Suppliers will also be monitored, where there have been multiple claims for the same supply of prescription under the Pharmaceutical Benefits Scheme. As with Medicare payments, the Department will seek to recover any overpayments.
  • The Department has identified optometrists’ billing of certain computerised perimetry test items as another area of focus. The billing of perimetry test items will be monitored to ensure that they fit within the item descriptor in the Medicare Benefits Schedule. The Department will also focus on the use of marketing and induction programmes by optometrists, which can result in the over-servicing of patients.
  • Requests for radiology services and diagnostic imaging practices will also be an area of focus. The Department has indicated that it will continue to review health professionals, including chiropractors and dentists, whose pattern of radiography and diagnostic imaging requests changes significantly.
  • The Chronic Disease Dental Scheme closed in 2012, with Medicare billing ceasing for services provided after 30 November 2012. The Department has indicated that in 2013–14 it will finalise all Chronic Disease Dental audits and complaints.

If you have any questions, please do not hesitate to contact Principal Kellie Dell’Oro.

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