Medicare compliance scrutiny has increased significantly. GPs can be audited, placed under review through the Practitioner Review Program, or issued with formal compliance notices. Understanding what triggers these processes — and how to respond — is essential. Contact your medico-legal insurer before responding to any formal compliance communication.
Medicare billing is one of the most technically complex areas of general practice. Doctors are expected to be familiar with hundreds of item numbers, their clinical descriptors, associated requirements, and the rules governing their interaction — all while seeing patients. Against this backdrop, it is perhaps unsurprising that billing errors occur.
What many GPs do not fully appreciate is that billing errors can attract serious consequences: repayment demands, professional scrutiny, conditions on Medicare provider status, and in cases of deliberate fraud, criminal charges. The Medicare Benefits Schedule (MBS) is a legal framework, not a guideline — and Services Australia takes compliance seriously.
What Is the Practitioner Review Program?
The Practitioner Review Program (PRP) is Services Australia’s primary mechanism for reviewing the billing practices of individual practitioners. It is a compliance framework designed to identify and address billing patterns that fall outside statistical norms or that suggest non-compliance with MBS requirements.
The PRP can be triggered in several ways:
- Statistical analysis identifying billing patterns that are outliers compared to peers
- Patient or third-party complaints about billing
- Referrals from other agencies, including AHPRA
- Tip-offs or whistleblower reports
- Audit activity across specific item numbers identified as high-risk
The PRP is not a criminal investigation — at least not initially. It is a compliance review. However, it can escalate, and the findings of a PRP review can be referred to the Professional Services Review (PSR) for formal investigation.
The Professional Services Review: A More Serious Process
If the PRP identifies concerns that cannot be resolved through education or voluntary repayment, the matter may be referred to the Professional Services Review (PSR). The PSR is an independent statutory body with significant powers, including the ability to:
- Require repayment of Medicare benefits
- Issue written reprimands
- Impose conditions on a practitioner’s right to access Medicare
- Suspend or disqualify a practitioner from providing Medicare-eligible services
- Refer findings to AHPRA
PSR proceedings are serious and can have permanent consequences for a GP’s ability to practise. Legal representation at this stage is not optional — it is essential.
Critical: Respond at Every Stage: Many practitioners make the mistake of not taking the early stages of the PRP process seriously, or of responding without legal advice. Every communication from Services Australia or the PSR is a formal document in a legal process. Do not respond to any compliance notice, request information, or invitation to a PRP interview without first speaking to your medico-legal insurer.
Common Medicare Billing Errors GPs Need to Know About
The majority of GPs who attract compliance attention are not engaged in deliberate fraud. The most common issues arise from genuine misunderstanding of MBS requirements. Understanding the most frequently cited errors is the first step to reducing your compliance risk.
1. Incorrect Time-Based Item Number Claiming
Several Medicare item numbers — including the Level B, C, D, and E consultation items — have minimum time requirements. A Level C consultation, for example, requires a consultation of at least 20 minutes in which the practitioner is present. Claiming a Level C when the clinical record does not support a 20-minute consultation is one of the most common compliance issues identified in GP audits.
Your clinical notes should document the duration and clinical content of each consultation. ‘Start’ and ‘finish’ times are not always required but are helpful evidence in a compliance review.
2. Claiming Duplicate Items
Some Medicare items cannot be claimed together on the same day or within specified time periods. For example, certain procedural items cannot be claimed alongside specific consultation items. The MBS Online tool and item descriptor notes identify these restrictions — failing to check them is a common source of errors.
3. Incorrect Use of After-Hours Items
After-hours item numbers are among the most scrutinised by Services Australia. The claiming rules specify the time periods during which after-hours items can be claimed, the requirement for an urgent need to attend, and documentation requirements. Practices that claim disproportionately high rates of after-hours items relative to peers are frequently flagged for review.
4. Multiple Attendances on the Same Day
As a general rule, Medicare does not allow billing for more than one consultation with the same patient on the same day. There are limited exceptions — such as where a second attendance is for a distinctly different condition. These exceptions are narrow and well-defined. Routine double-billing for same-day consultations is a compliance red flag.
5. Claiming for Services Not Rendered
Claiming Medicare benefits for services that were not actually provided — whether intentionally or due to administrative error — is not just a compliance issue. It is a criminal offence under the Criminal Code Act 1995. Even where there is no intention to defraud, systemic over-claiming can result in serious consequences.
6. Inappropriate Health Assessments and GP Management Plans
Health assessment items (such as 715 for Aboriginal and Torres Strait Islander health assessments) and GP Management Plan items (such as 721) have specific eligibility criteria. Claiming these items for patients who do not meet the criteria, or without completing the required components of the assessment or plan, is a common compliance concern.
Clinical Scenario: The PRP Letter: Dr Morrow receives a letter from Services Australia advising that her billing patterns for Level C consultations have been identified as an outlier compared to practitioners with similar patient profiles. She is invited to attend a PRP interview to discuss her billing practices.
What Dr Morrow should do: Contact her medico-legal insurer immediately. Do not attend the PRP interview without representation. Gather a sample of clinical records for the time period under review — ideally with legal guidance about which records to produce. Review whether the clinical documentation supports the item numbers claimed. Engage a Medicare billing expert if needed to review her billing practices prospectively.
How to Respond to a Medicare Compliance Notice
A Medicare compliance notice is a formal document that requires a response. The process for responding effectively follows a consistent pattern:
Step 1: Contact Your Medico-Legal Insurer Immediately
This is the single most important step. Your insurer can connect you with practitioners experienced in Medicare compliance matters and help you navigate the process. Do not respond without this support.
Step 2: Identify the Scope of the Review
What item numbers or time period are under scrutiny? Understanding the scope of the review helps you identify which clinical records are relevant and where to focus your review.
Step 3: Conduct an Internal Audit
With legal guidance, review a sample of records for the period and item numbers in question. Identify whether your clinical documentation supports the claims made. This is not about building a defence — it is about understanding your actual position before you communicate with Services Australia.
Step 4: Respond Accurately and Completely
Your response to a compliance notice should be factual, accurate, and complete. Do not overstate the strength of your documentation, and do not minimise genuine errors. If errors have occurred, voluntary disclosure and repayment can mitigate consequences.
Step 5: Implement Prospective Changes
Demonstrating that you have identified the issue and implemented changes to your billing and documentation practices is a significant mitigating factor. This should be documented and, where relevant, communicated to Services Australia as part of your response.
Telehealth and Medicare Compliance
The expansion of telehealth following the COVID-19 pandemic introduced new Medicare items and new compliance risks. Some of the most common telehealth compliance issues include:
- Claiming telephone consultation items where the MBS requires a video consultation
- Claiming telehealth items for patients who are not eligible under the applicable rules (e.g., patients within certain distances of the practice)
- Failing to satisfy the practitioner-patient relationship requirements that apply to telehealth items
- Incorrect claiming of bulk billing incentives in connection with telehealth consultations
The rules governing telehealth items have changed significantly since 2020 and continue to evolve. Check the current MBS item descriptors at www.mbsonline.gov.au before claiming.
Preventive Strategies: Reducing Your Medicare Compliance Risk
The best response to a Medicare audit is never having one. The following practices significantly reduce compliance risk:
- Document duration and clinical content for every consultation — particularly for time-based items
- Use MBS Online to verify item descriptors and billing rules before claiming new or unfamiliar items
- Conduct periodic internal audits of your own billing patterns — compare your patterns to published peer benchmarks
- Review your practice software settings — many billing errors are caused by default settings in clinical software that automatically apply item numbers without clinical verification
- Train reception and billing staff — many claims are entered by administrative staff who may not understand the clinical requirements
- Stay current with MBS changes — item descriptors, time requirements, and claiming rules change regularly
Frequently Asked Questions
Q: Can I be audited without having done anything wrong?
Yes. Statistical outlier analysis identifies practitioners whose billing patterns differ from peers — this can reflect genuine clinical differences in patient population or practice type, not just non-compliance. However, you will still need to justify your billing patterns if selected for review.
Q: What is the difference between a PRP interview and a formal PSR investigation?
A PRP interview is an early-stage compliance review conducted by Services Australia. It is less formal than a PSR investigation and may resolve without referral. A PSR investigation is a formal statutory process with broader powers and more serious potential consequences. Most matters are resolved at the PRP stage if handled well.
Q: If I discover I’ve made billing errors, should I self-report?
Voluntary disclosure is generally viewed favourably by Services Australia and can reduce the severity of consequences. However, you should seek legal advice before making any voluntary disclosure, as the scope and framing of what you disclose matters.
Q: Can Medicare compliance issues affect my AHPRA registration?
Yes. PSR findings can be referred to AHPRA, particularly in cases involving serious non-compliance or dishonesty. This means a Medicare matter can evolve into a registration matter. Early legal advice is critical.
Q: My practice manager handles all billing — am I still responsible?
Yes. As the treating practitioner, your Medicare provider number is used to generate the claim, and you bear ultimate responsibility for the accuracy of claims made under your provider number. Delegation to administrative staff does not remove your legal liability.
