Over the last few years Medicare has been increasing its audit activity where it suspects practitioners of inappropriate billing.  Medicare has had recent success in recovering over payment of Medicare benefits from practitioners and we expect that its audit activity will continue and is likely to be expanded.

While some inappropriate billing may be inadvertent, the reality is that responsibility for correct claiming rests with the practitioner.

Medicare billing is often delegated to non-practitioners and can be administered through centralized billing areas that can be influenced by organizational processes and policies.

We are aware of situations where inappropriate billing has occurred at the practice administration level, the doctor themselves being unaware.  However, following an audit the doctor (as the holder of the provider number) has been held responsible for the full repayment of the overpaid benefits, despite the doctor and the practice having jointly benefitted from the overpayment.  In at least one incident the practice also terminated the doctor’s employment for a ‘breach of professional standards’.

In response to the way billing may be conducted within practices and in acknowledgement that corporatised practices may benefit from and/or contribute to inappropriate billing, on 1 July 2019 Medicare introduced the Shared Debt Recovery Scheme.  The Scheme enables Medicare to make a shared debt determination and apportion the debt recovery between the doctor and practice entity.

Medicare’s intent in introducing the Scheme is to encourage practitioners and the practice organization to work together to ensure billing is correct, improve response to Medicare audits and promptly repay any debts that may arise.

Where you receive notification of a Medicare audit, we encourage you to contact our Claims & Legal Services team for advice and support in dealing with the matter.

Importantly, practices holding Professional Indemnity insurance with MIGA can also make use of our Claims & Legal Services team for advice and support on these issues and again we encourage early notification to enable us time to assist you.

Access to advice and support is an important additional benefit of insuring with MIGA and we encourage you to utilize our expertise in this area.

A more detailed fact sheet outlining the operation of the Shared Debt Recovery Scheme is available from the Department of Health’s website (see below).

Suspected inappropriate billing identified by Medicare follows an escalation process through Medicare and the PSR.  Our Team can provide advice and assistance to help you understand and navigate this process.

Our risk education hypothetical, “Medicare, does your dawg bite” presented at our Risk Management Conferences provides insight to the process and our panelists have first-hand experience.  Find out more by attending this interactive and entertaining discussion – book your place at a Conference via REO (Access via the top menu of our website homepage).

Other resources

  1. Fact Sheet

    Operation of the Shared Debt Recovery Scheme

Prefer to read a PDF of the Bulletin? Download it here

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