DoHAC plans to zero in on business models prioritising money over care, threatening clinical independence or charging membership fees.
The Department of Health and Aged Care has released a list of eight compliance areas it plans to crack down on in 2025, including membership fees, opportunistic billing and emerging business models.
They are as follows:
- bulk billing, particularly membership fees;
- opportunistic billing and emerging business models;
- duplicate payments;
- claiming MBS services while overseas;
- suspected fraud;
- specialist and consultant physician claiming of attendance items and management plans;
- inappropriate claiming of high-cost PBS medicines; and
- open and uncertified PBS claims.
One of DoHAC’s priorities, when it comes to bulk-billing compliance, will be co-payments and administration fees.
The department reiterated that any additional charge levied for a bulk-billed services was in breach of the Health Insurance Act 1973.
“Where we find that a health professional has charged a co-payment or membership fee for a bulk-billed service, we take compliance action,” reads the priorities list.
As reported by The Medical Republic last month, the department recently stated at it had 12 open cases relating to healthcare providers charging additional fees when bulk billing.
The government said it had growing concerns over business models with misaligned priorities.
“In an environment of rising costs, technology advancements and innovation in healthcare delivery, there is increasing risk of business models prioritising revenue generation over clinically relevant patient care,” it said.
“The integrity of Australian government health program payments is impacted 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.”
Speaking to The Medical Republic, the RACGP’s Medicare compliance lead GP Dr Tony Bayliss said he had seen a turning of the tide in recent years in relation to the department’s compliance strategy.
“There has been a philosophical shift towards education and support following the Phillip review, which is demonstrated in the recent semaglutide letters, which focus on education, rather than punishment,” he said.
Earlier this month, over a thousand GPs across the country received letters from the department raising concerns over their semaglutide prescribing.
The letter encouraged GPs only to prescribe only where PBS criteria have been met, ie when there was a history of type 2 diabetes.
Dr Bayliss said the RACGP would be providing additional material on complying with MBS rules in the near future.
“MBS and PBS compliance continue to be complicated and challenging, so a collaborative approach is welcomed,” he said.
According to DoHAC’s 2025-2030 health provider compliance strategy, compliance priorities focus on the severity and scale of harm posed to the Medicare system.
Related
“Our published compliance priorities reflect our commitment to act,” it reads.
“The department also monitors and plans for environmental changes, meaning that compliance priorities may evolve in response to emerging risks.”
The department told TMR that “GPs simply need to be compliant”.
“In relation to the published priorities, GPs are reminded: the department’s preferred approach to achieving compliance is through prevention and education.
“The Understanding Medicare: Provider Handbook has been developed to provide core guidance for GPs and others navigating the Medicare system.”
The agency said GPs should be reminded that Medicare benefits cannot be claimed when services are performed overseas, even via telehealth, and that all GPs were responsible for any services claimed under their provider number.
