Medicare Update

On the compliance front, the Department of Health, Disability and Ageing (the Department) released its priorities for 2025,¹ including the following:

Suspected fraud

The Department is committed to tackling illegal activity and behaviour of concern to protect the integrity of Medicare.

Bulk billing

Charging a co-payment or membership fee is a breach of the Health Insurance Act 1973. Where the Department finds that a health professional has charged a co-payment or membership fee for a bulk-billed service, it will take compliance action.

Specialist and consultant physician claiming of attendance items and management plans

Data shows specialist and consultant physician attendance items drove the growth of attendance services in financial year 2023-24. This includes management plans such as MBS items 132 and 133. The Department’s focus is on ensuring providers understand how to claim correctly to protect the sustainability of Medicare.

Claiming MBS services while overseas

Medicare benefits are only payable where the service is performed in Australia to an eligible patient. 5,800 doctors have received either a schedule for self-audit (and possible repayment) or an education letter reminding them of the requirement for both the doctor AND the patient to be located in Australia for a Medicare item to be billed.

If you receive a schedule for self-audit, please contact MDA National for advice.

Opportunistic billing and emerging business models

The Department is alert to the increasing risk of business models prioritising revenue generation over clinically relevant patient care. The integrity of Australian Government health program payments is impacted (and action may be taken) where:

• arrangements between an organisation and a health professional remove health provider control over their claiming; or
• a practitioner’s clinical independence is undermined by corporate billing requirements.

Duplicate payments Medicare benefits are only payable where a service has not already been paid for through another funding arrangement. Duplicate payments breach section 19 of the Health Insurance Act 1973. This requirement ensures the sustainability of Australia’s healthcare system.

In other news…

The 80/20 and 30/20 rule

In addition to the Department’s compliance priorities, we have also been contacted by Members who are either very close to or already breaching the 80/20 rule and/or the 30/20 rule.

75% vs 85% for a service rendered as part of an episode of hospital treatment

We have also seen targeted compliance around the incorrect claiming 85% of benefits, instead of 75%, for an episode of hospital treatment or privately insured hospital-substitute treatment.

The new Chronic Disease Management items are finally here!

The Department has released details around the long-awaited changes to the Chronic Disease Management Framework which came into effect on 1 July 2025.

Further information can be found on the fact sheet Upcoming changes to the MBS Chronic Disease Management Framework on the MBS online webpage² – and keep an eye out for our Medicare webinar coming up later in the year where we will discuss the changes in more detail.

References

1. health.gov.au/resources/publications/health-provider-compliance-priorities-2025?language=en
2. mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-Current