For medical practitioners to claim benefits under Medicare, they must comply with the provisions of the Health Insurance Act 1973 (Cth) and the Medicare Benefits Schedule (MBS). These obligations include:
- only claiming for clinically relevant services that are rendered in Australia;
- honestly selecting and allocating MBS item numbers for services provided;
- billing and claiming correctly;
- keeping accurate records – and being able to produce them to substantiate Medicare claims if required; and
- reporting incorrect claims to Medicare as soon as errors are detected.
Medicare compliance
The Commonwealth Department of Health and Aged Care (DoHAC) administers Medicare and monitors benefits paid. To ensure that practitioners comply with their obligations, DoHAC systematically reviews and audits practitioners’ claims through education, targeted letters, audits and investigations. DoHAC recently contacted MIPS to advise that it will be increasing its targeted compliance monitoring of overseas billing.
Overseas Medicare billing
Section 10 of the Health Insurance Act 1973 only permits payment of Medicare benefits for professional services provided in Australia. This means that both the practitioner and patient must be in Australia when the service is performed.
This applies to all services for which an MBS claim is made, including services:
- the practitioner personally performs
- performed by a non-medical practitioner under the practitioner’s supervision (supervised services)
- provided in-person
- provided via telehealth.
Medicare benefits cannot be claimed for services provided while either the practitioner or patient are outside Australia.
Complying with a targeted compliance letter
Practitioners who receive a letter will be asked to
- review their servicing to ensure they meet the MBS requirements and that services provided are clinically relevant; and
- ensure future services are not billed to their provider number while overseas; and
- voluntarily acknowledge incorrect payments using a specific form if DoHAC identifies any incorrect payments.
We strongly recommend that members contact MIPS as soon as they receive any correspondence from DoHAC in relation to their Medicare billing. Members should not speak with DoHAC unless or until they have received advice from MIPS. This ensures that MIPS can provide timely advice and protect their interests.
Tips for reducing the risk of inadvertent MBS billing while you are overseas
DoHAC encourages practitioners who are travelling overseas to temporarily close their provider number and reopen them upon their return. It also recommends that practitioners regularly check who has access to their provider number and check their billings to ensure that they are correct.
Overseas indemnity insurance cover
The rule against overseas Medicare billing does not prevent practitioners from privately billing patients for care provided overseas. If MIPS members intend to provide privately-billed healthcare while they or their patients are overseas, they should check whether they are required to hold registration and local insurance in that country and comply with any requirements.
They should also check their MIPS Indemnity Insurance Policy to ensure they are covered. Subject to the full terms and conditions of the MIPS Indemnity Insurance Policy, members should be aware that they are only covered for overseas healthcare where:
- the member was outside Australia for <120 days in the aggregate during the policy period and the patient was in Australia; or
- the patient was outside Australia for <90 days and the member was in Australia; and
- neither the patient nor the member were in the USA or anywhere that USA law applies.
Members should contact MIPS if they have any questions about their cover or Medicare’s compliance activities.
Medical Indemnity Protection Society ABN 64 007 067 281 | AFSL 301912
All information on this page is of a general nature only and is not intended to be relied upon as, nor to be a substitute for, specific legal or other professional advice. No responsibility for the loss occasioned to any person acting on or refraining from action as a result of any material published can or will be accepted by MIPS.
You should seek legal or other professional advice before relying on any content, and practise proper clinical decision making with regard to the individual circumstances.
Information is only current at the date initially published.
If in doubt, contact our claims and 24-hour medico-legal advice and support team on 1300 698 573.
You should consider the appropriateness of the information and read the Member Handbook Combined PDS and FSG before making a decision on whether to join MIPS.
