Medicare Compliance Priorities 2021-2022

Medicare compliance priorities 2021-2022

What will the Department of Health be paying extra attention to in the next 12 months?

The Department of Health has released the Health Provider Compliance Strategy, which identifies their compliance priorities for 2021-2022. 

To facilitate patient access to subsidised health services across Australia, providers may obtain public health funding through the Medicare Benefits Schedule (MBS), the Pharmaceutical Benefits Scheme (PBS), the Child Dental Benefits Schedule (CDBS) and Practice Incentive Programs (PIP). These programs operate on the expectation that providers will adhere to legislated rules, including eligibility requirements for practitioners providing services or medicines, and patients who receive them.

The Department of Health continues to prioritise the interests of patients and the integrity of the health payments system by monitoring any incorrect claiming, inappropriate practice and fraud. Action will always be prioritised to address practices that may: 

• Expose patients to a risk of harm; 
• Compromise the clinical independence of practitioners (e.g., in circumstances where claims do not reflect the provision of the clinically relevant service);
• Demonstrate repeated or wilful non-compliance by a person or entity; 
• Involve fraud. 

2021-2022 Compliance Priorities 

In 2021-2022, the Department will focus on the following compliance priorities: 

1. Referrals, Requests and Prescriptions
Valid referrals, requests and prescriptions are fundamental in safeguarding patient care and preventing the fraudulent obtaining of funds from health programs. The Department prioritises action in relation to the claiming for services or dispensing of medication without a valid referral, request or prescription, or beyond what was stipulated.  

2. Telehealth and Vaccination Administration
The Department’s evaluation of claims is essential to ensuring that the requirements for telehealth arrangements and vaccine administration are being met, in the context of the pandemic. This responds to the current needs of Australian patients and ensures these services are being used for their intended purpose. Trends in the claiming data, for example, the use of telehealth items for ‘pre-consultation screenings’ or the co-claiming of attendances and vaccine services without clinical justification, indicate instances of service misuse. 

3. Practice Incentive Payments
Analysing claims for incentive payments, in order to ensure the requirements for these payments are met and health outcomes for patients are not compromised, is a priority for the Department. This involves supporting policy reforms and improvements to the payment system, heightened eligibility checks and compliance post-payment. 

4. Corporate Compliance 
A further priority for the Department is reforming the compliance program in support of enforcement action for organisations or corporate health providers that over-service or provide low value care, for the purpose of maximising Medicare revenue. These kinds of arrangements compromise a practitioner’s control over their claiming, jeopardise clinical independence and threaten the integrity of health programs.  

If you receive correspondence from the Department or have any enquiries regarding Medicare compliance, please contact the Workplace Relations Team at workplace@amansw.com.au or (02) 9439 8822.

Article contributed by Dominique Egan & Cassie Christopher