bulk bill assignment of benefit form

• Login/Register
• Public Health
• The Back Page
• Humoural Theory
• Red Herring
• Wild Health 2024
• Join the Medical Republic
• Subscribe to Newspaper
• Subscribe to newsletter
• Past Issues
• Advertise with us

Thanks for bulk billing! Now here’s some forms

5 minute read

The rules for patient consent to be bulk billed are good news for the doctors who love paperwork, bad news for the other 99.99%.

Doctors who want to bulk bill patients for a telehealth appointment have a compulsory new form to fill out documenting a patient’s verbal consent, courtesy of Services Australia.

The only other alternatives are getting written consent via email, privately billing the patient or running the risk of repaying all those benefits in the event of an audit.

To be clear, collecting a patient’s written consent to bulk bill has been a longstanding – if somewhat obscure – requirement under subsection 20B paragraph 3c of the Health Insurance Act 1973.

When telehealth was introduced over the pandemic, Services Australia made a temporary exception and allowed practitioners to get verbal consent from patients and simply make a note of it in the consult notes.

That exception was flagged as ending in December last year, but was extended at the last minute so the Department of Health and Aged Care could develop what the AMA said would be a “solution that is more suitable for permanent telehealth services”.

At the time, the medical association said it hoped the department would take the opportunity to “streamline arrangements” and reduce paperwork.

This particular wish does not appear to have been granted.

Under the new arrangements, doctors can still collect verbal consent to bulk bill – but they will have to follow it up by completing an online form which then has to be sent to the patient via email or text.

There are two approved forms to choose from: bulk bill voucher electronically transmitted claims form DB4E and assignment of benefit Medicare bulk bill webclaim form DB020 , the latter of which can only be used in conjunction with HPOS Medicare bulk bill webclaim.

Services Australia instructs doctors to type “patient verbally agreed” in the patient signature field of these forms, but only after discussing this with the patient .

Alternatively, GPs can email a patient to ask for written consent to bulk bill if they’ve done a telehealth appointment.

This is also a multi-step process.

First, the doctor needs to tell the patient during the consult that they plan to bulk bill.

Then, the doctor has to send an email to the patient’s nominated email address with the details of the service – including item numbers, benefit amounts and the date/time of service – the customer statement and a privacy notice.

Including the patient’s Medicare card number or the doctor’s provider number in this email is apparently a no-no, presumably for privacy reasons.

The patient then replies to that email, explicitly writing that they agree to the assignment of the Medicare benefit directly to the health professional.

Only once that is done can the doctor complete general, specialist and diagnostic assignment of benefit voucher form DB4 and submit the claim, writing “email agreement” in the signature block.

A copy of the form also must be sent to the patient.

The Albanese gov’t tripled GP incentives for bulk billing, woohoo! Now they introduce the requirement for a signed patient consent form in order to bulk bill a telehealth consultation! ??How is that meant to work? ? ?? #BulkBilling #TELEhealth #Medicare — Dr Rob Mathews (@robmathews) October 2, 2023

The third and final way to get bulk billing consent from a patient for a telehealth appointment is to obtain a physical signature via snail mail.

The new arrangements first appeared in a DOHAC fact sheet dated September 18 and took effect immediately.

In the fact sheet, DOHAC credited the new requirements to prove verbal consent to an Australian National Audit Office report on Medicare telehealth services released in January.

That ANAO report found that verbal consent for bulk billing created a fraud risk.

To spell it out: if there’s no patient acknowledgement that the consult being billed by the doctor actually happened, Services Australia could potentially be defrauded by GPs $38 at a time.

The ANAO also found that DOHAC officials had not only failed to properly assess the legal implications of verbal consent before putting it in place, but also outright ignored concerns from staff members about the potential for fraud as early as March 2020.

The report is about as snippy as official wording allows and takes the department to task for not clarifying to doctors that the verbal consent policy might not meet the legal requirement to provide patients with a copy of what they’re getting bulk billed for.

Bulk billing? You need the patient's signature

The consent rule half of GPs don’t know about

Bulk billing consent must be recorded in tapestry

“The legal consequences of failing to observe such requirements can be severe [for practitioners],” the ANAO wrote.

“Where a provider does not provide a copy of the signed agreement in approved form to the patient, there is no legal basis for Services Australia to pay the benefit to the provider.

“Additionally, providers can be criminally liable for failing to complete the agreement form properly.”

It led to a recommendation that DOHAC develop better procedures for structured and documented risk assessments whenever there’s a change to the MBS, which the department accepted.

Failure to have a signature from the patient acknowledging their consent to being bulk billed makes an entire claim non-compliant, meaning Medicare can theoretically demand repayment.

If it considers the non-compliant claims to be fraudulent in nature, there’s every chance that Medicare will also refer that doctor to the Commonwealth Director of Public Prosecutions.

DoHAC has reportedly assured the RACGP that no retrospective compliance will be carried out on this front.

Generally, however, doctors are advised to keep a copy of all correspondence, claims and forms for at least two years for auditing purposes.

College president Dr Nicole Higgins said she would raise the issue with DoHAC and Health Minister Mark Butler on behalf of members.

End of content

No more pages to load

Register for a new account

Billing address, payment information we accept visa, mastercard, american express, and discover.

• Private Hospital Billing
• Locum Arrangements
• Co-Claiming
• Fee Setting
• Seeking Advice
• Bulk Billing
• Supervision Rules
• Public Hospital billing
• Provider Numbers

Specialities

• General Practice
• Oncology and Haematology
• Rehabilitation Medicine
• Gastroenterology
• Nephrology and Renal Medicine
• General Surgery
• Geriatricians
• Anaesthesia
• Emergency Medicine
• Nurse Practitioners

Does the patient have to sign the bulk bill voucher?

Date of Answer: 12:06 pm  I  August 1, 2020

BB 2020/061

It is commonly believed that patients do not have to sign the bulk bill voucher. This is incorrect. The law is clear that the patient’s signature evidencing consent to bulk bill is always required.

This answer explains the law around the requirement for patients to sign the Bulk Bill voucher, commonly known as the DB4 form.

Relevant legislative provisions

Health Insurance Act 1973 , Section 20A

Health Insurance Act 1973 , Section 20B(3)

Health Insurance Act 1973 , Section 127

Health Insurance Regulations 2018, Reg 63(2)(b)

Electronic Transactions Act 1999

Other relevant materials

1. Short bulk bill explainer article published in Australian Doctor:

The Law Trumps Medicare Advice on Bulk Bill Vouchers: https://www.ausdoc.com.au/workwise/youre-likely-guilty-so-beware-law-trumps-medicare-advice-bulk-bill-vouchers

2. Peer reviewed academic journal article published in the Journal of Law and Medicine, with detailed analysis of bulk billing arrangements:

Medicare Billing Law and Practice: Complex, Incomprehensible and Beginning to Unravel. https://www.ncbi.nlm.nih.gov/pubmed/31682343

Wong v Commonwealth of Australia;  Selim v Lele, Tan and Rivett constituting the Professional Services Review Committee No 309 [2009] HCA 3 (2 February 2009) 

Departmental interpretation

https://www.servicesaustralia.gov.au/organisations/health-professionals/services/medicare/medicare-online-health-professionals (accessed 6 June 2020)

“Assignment of benefit documents

Assignment of benefit forms no longer need to be stored at the practice if you are using Medicare Online. ..

The legislative requirements for the assignment of benefit are:

• an agreement must be made between the patient (assignor) and you for the assignment of benefit
• the agreement is evidenced through the use of the assignment of benefit form
• the patient is required to sign the form
• a copy of the agreement must be provided to the patient.”

Detailed reasoning

Section 20A(1) of the Health Insurance Act (the Act) describes the bulk billing process as follows (my underlining):

“Assignment of Medicare benefit

(1)  Where a medicare benefit is payable to an eligible person in respect of a professional service rendered to the eligible person or to another eligible person, the first‑mentioned eligible person and the person by whom, or on whose behalf, the professional service is rendered (in this subsection referred to as the practitioner) may enter into an agreement, in accordance with the approved form, under which:

(a)  the first‑mentioned eligible person assigns his or her right to the payment of the medicare benefit to the practitioner; and

(b)  the practitioner accepts the assignment in full payment of the medical expenses incurred in respect of the professional service by the first‑mentioned eligible person.”

There are two parties described in Section 20A. The first is the ‘eligible person’ which is the patient, and the second is the ‘practitioner’ which may be a doctor or any health provider able to claim using the medicare scheme.

Section 20A states that the patient holds the legal right to the medicare benefit, not the practitioner. A simple two step process (known as bulk billing) is set out, whereby the patient assigns their right to a medicare benefit to the practitioner, and the practitioner accepts it in full payment for the service provided.

Implicit in this arrangement is the concept of consent.

In deliberations around the operation of Section 20A, Kirby J, in the High Court case of Wong v Commonwealth of Australia said:

“Even “bulk billing” is only possible by consent of both parties to that relationship.”

The method of consent is described in Section 20B(3) of the Act. This is where the patient’s signature comes into play. The Act states that the patient has to sign the assignment of benefit form to evidence their consent to being bulk billed.

Here is section 20B(3) with the word ‘signed’ underlined.

“(3)  A claim referred to in subsection (2) shall not be paid unless the claimant satisfies the Chief Executive Medicare that:

(c)  in the case of an agreement under subsection 20A(1) that was signed by each party in the presence of the other—the assignor retained in his or her possession after the agreement was so signed a copy of the agreement;”

The content on the Department’s website (above, under the heading Departmental Interpretation) is likely the cause of widespread non-compliance with the signature requirement, because it is confusing.

However, it is important to understand that the department saying you do not have to keep the signed form, does not mean the patient does not have to sign it.

The law is clear – the patient has to sign the assignment of benefit form to evidence consent, and the fact that the department permits putting your copy of the signed form in the bin, in no way negates the provisions of the Act.

From the government perspective, continuance of the signature requirement is good policy, designed to protect the integrity of public money, in two ways:

• It is the only active involvement the patient has in a bulk billing transaction, and it therefore provides the only opportunity for the patient to review and query the services being claimed against her/his Medicare number, and
• It is a critically important safeguard against fraudulent billing (such as billing for fictitious services) because it is the only evidence of both the practitioner and patient being in the same place at the same time.

From the practitioner perspective, retaining copies of signed bulk bill vouchers is a good idea, because it evidences practitioner presence and patient consent. Entries in clinical records cannot do this to the same extent. For example, an unethical practitioner could easily make an entry in a clinical record for an existing patient, without having provided a service, and the patient would likely never know that a claim had been bulk billed under their Medicare card.

The department’s position is unfortunate, however, it is there in black and white on their website. So, if you are bulk billing electronically, the department has made clear, the decision to retain or bin signed bulk bill vouchers is a matter for you.

Section 20A and 20B are two of the key machinery provisions of the Act, underpinning the operation of the Medicare scheme. Think of them like pulmonary veins that deliver oxygenated blood to the heart. These sections deliver approved payments of taxpayer’s money to your pocket. Removing them from the scheme would obliterate patient consent and render the scheme more vulnerable to abuse.

Examples and other relevant information

Other important legal provisions relating to bulk billing that you should be aware of.

• Asking patients to sign blank bulk bill forms or forms with missing details is illegal per Section 127 of the Act .
• Not giving patients a copy of their signed bulk bill form is an offence, but penalties can be waived if you have a ‘reasonable excuse’ as to why you didn’t give it to the patient. This is also in Section 127.
• Using a Medicare Easyclaim terminal has a special legal provision, so having the patient (not you) press ‘yes or ‘OK’ on the terminal is a legally valid signature, per regulation 63(2)(b).
• If the patient is unable to sign, you can indicate ‘unable to sign’ and notate why. This has always been an available option on the prescribed form (the DB4).
• Medicare is a fee-for-service scheme meaning you must obtain the patient’s consent for each separate service. It is not permissible to obtain a blanket ongoing consent to bulk bill, such as for a course of chemotherapy.
• The Department is bound by the provisions of the Electronic Transactions Act 1999 and so SMS/email signatures are permitted, providing certain criteria are met. This will help you to understand how to manage the bulk bill signature requirement in situations where the patient is not physically in the same place as the practitioner when the service is provided, such as case conferences and telehealth. See answer BB2020/062 .

Who this applies to

Everyone when bulk billing.

When this applies

Always. This has been the law since Medibank (later Medicare) began.

Relevant AIMAC courses

Bulk Billing, Medicare’s Heart Beat

Date of Answer: 1:37 pm  I  September 21, 2020

• Bulk billing is only permissible AFTER a service has been provided and fees have been incurred in respect of a professional service. Therefore, do not ever ask a patient to sign a bulk bill voucher (even if all data elements have been completed) before a service has been provided. Patients cannot be asked to sign for a service they have not received.

Date of Answer: 5:54 pm  I  January 16, 2023

Date of Answer: 1:52 pm  I  February 23, 2023

Health Insurance Act 1973 , Section 20B(3)

Health Insurance Act 1973 , Section 127

2. Academic journal article published in the Journal of Law and Medicine, with detailed analysis of bulk billing arrangements:

Wong v Commonwealth of Australia;  Selim v Lele, Tan and Rivett constituting the Professional Services Review Committee No 309 [2009] HCA 3 (2 February 2009) 

(1)  Where a medicare benefit is payable to an eligible person in respect of a professional service rendered to the eligible person or to another eligible person, the first‑mentioned eligible person and the person by whom, or on whose behalf, the professional service is rendered (in this subsection referred to as the practitioner) may enter into an agreement, in accordance with the approved form, under which:

(a)  the first‑mentioned eligible person assigns his or her right to the payment of the medicare benefit to the practitioner; and

(b)  the practitioner accepts the assignment in full payment of the medical expenses incurred in respect of the professional service by the first‑mentioned eligible person.”

“(3)  A claim referred to in subsection (2) shall not be paid unless the claimant satisfies the Chief Executive Medicare that:

(c)  in the case of an agreement under subsection 20A(1) that was signed by each party in the presence of the other—the assignor retained in his or her possession after the agreement was so signed a copy of the agreement;”

Date of Answer: 3:51 pm  I  March 1, 2023

Date of Answer: 2:27 pm  I  May 15, 2023

Date of Answer: 3:14 pm  I  June 5, 2023

Whether patients need to sign something when being bulk billed causes a great deal of confusion industry wide. The confusion is understandable given Medicare itself advises that you do not need to retain signed bulk bill vouchers. But what does that actually mean and what does the law say?

Date of Answer: 3:15 pm  I  June 5, 2023

Subscribe to mbsanswers.com.au

Signup to receive instant updates when new or revised answers have been posted. If you have posted a question this is the quickest way to be notified that the answer is available.

Medicare and Digital Signing of DB4 Benefit Assignment Forms

The executive summary is that GP2U now offers Australia's only Medicare approved digital signing of DB4 form process. With a couple of mouse clicks a patient can now legally assign their Medicare benefits to a remotely located specialist. The background to this ground breaking eHealth development is presented below.

What section 20A says is that a patient can assign their Medicare benefit to their treating doctor by signing the approved form, where the approved form is the form approved in writing by the minister. The approved form is called a DB4 form .

With the advent of Telehealth a problem arises. How does a Specialist obtain the signature of a patient who is not in the same physical location? The initial Medicare advice to doctors was that a patient's verbal consent over a video conference link would be accepted as satisfactory for the purposes of Section 20A and the assignment of patient Medicare benefits. Earlier this year that advice was revoked and replaced with advice that doctors could either get a physical signature using paper DB4 forms and regular mail, or use an email process.

At GP2U our core focus is on making Telehealth easy. Sending physical DB4 forms by ordinary mail, or using a complicated email process, that, like verbal assignment of benefits process that preceded it appears non compliant with the requirements of section 20A, seemed to be making Telehealth harder - so we started thinking.....

The Electronic Transactions Act (1999) sets out the requirements for a digital signature. The GP2U process for a digital signature follows the industry standard MD5/RSA algorithm as specified by the World Wide Web Consortium (W3C). W3C is the peak organisation largely responsible for Internet standards. The detailed W3C technical specification for a digital signature is found here .

" In relation to the digitally signed DB4 it appears, based on the information you have provided, that your model would meet the requirements of the Health Insurance Act 1975 (the HIA) for the assignment of Medicare benefits"

You can read the full text of the Medicare approval letter here .

Advertising

Jolyon Attwooll

Review of bulk billing consent requirement flagged

DoH is looking into ‘assignment of benefit’ requirement for bulk billing, with the arrangement under the spotlight due to telehealth.

Hey Twitter This is tucked away in the latest changes in Medicare Covid measures. Don't be surprised if you can't get bulk billed telehealth because 1. The rebate is inadequate 2. It's now much harder, because you need to agree to be bulk billed in writing! pic.twitter.com/A8h2wILePu — Dr Tim is Musk free on @[email protected] (@timsenior) December 13, 2022

assignment of benefit bulk billing MBS Medicare telehealth verbal consent

Falling bulk billing rates a ‘sign of things to come’, RACGP warns

Gp funding boost overlooked in grattan medicare plan, your mixed billing questions answered, ‘robust framework’ key to telehealth best practice: racgp, assignment of benefit process ‘fundamentally flawed’: racgp, in practice: updated psr guide.

Login to comment

What does my patient need to do for a Bulk Billed transaction

A Bulk Billed transaction (from within the Tyro Health Online portal) does not require  an SMS approval step from your patient. To submit the bulk bill claim, your patient will need to provide you with their full name, date of birth and their Medicare card details. 

Once the Bulk Bill claim has been submitted, Tyro Health Online provides the ability for you to print the ‘Medicare Online Claiming - Bulk Bill Assignment of Benefit Form’ (DB4) for your patient to sign and keep.

You can obtain a DB4 by selecting any bulk bill invoice, scrolling to the bottom of the invoice and hitting "Print statement" in the Medicare statement section.

For more information and full instructions for creating a Bulk Billed transaction, refer to this article.

Medicare Benefits Schedule / Medicare compliance - Summary of useful links

Summary of useful links.

The RACGP has compiled links to information about the Medicare Benefits Schedule (MBS) and Medicare compliance so you can easily access these from one central location.

This page includes Department of Health and Aged Care, Services Australia and RACGP resources.​ Links are grouped under key themes, which are in alphabetical order.​ We’ve also included short descriptions of each resource to help you find what you need.

Resources on this page include MBS explanatory notes, education guides, fact sheets, eLearning programs and infographics. We encourage you to bookmark this page for easy reference. If you identify that any links on this page aren’t working or are no longer available, please let us know by emailing [email protected] .  

Education guide – Aftercare or post-operative treatment

• This guide contains information about aftercare in the MBS. Aftercare is the post-operative care and treatment provided to patients after an operation.
• This module contains information about aftercare in the MBS.
• understand what aftercare or post-operative treatment is
• identify when you can and can’t charge an MBS attendance item following a procedure
• identify the requirements of aftercare.
• Outlines claiming requirements for the following MBS items: 585, 588, 591, 594, 599, 600, 5000, 5003, 5010, 5020, 5023, 5028, 5040, 5043, 5049, 5060, 5063, 5067, 5200, 5203, 5207, 5208, 5220, 5223, 5227, 5228, 5260, 5263, 5265 and 5267.
• Outlines claiming requirements for the following MBS items: 3-4, 23-24, 36-37, 44, 47, 193, 195, 197, 199, 585, 594, 599, 2497-2559, 5000-5067 and 90020-90051.
• Outlines claiming requirements for MBS item 90001.
• A list of MBS items for services provided in residential aged care facilities.
• Contains information on billing Medicare items for Relative Value Guide services.
• Medicare benefits for anaesthesia services are calculated using the Relative Value Guide (RVG). The RVG is based on a unit system. It reflects the complexity and time taken for the service.
• This module explains the key requirements to claim Medicare benefits for anaesthesia services.
• After completing this module, you’ll have a better understanding of account and billing matters relating to the Relative Value Guide.
• A table listing the correct order to bill anaesthesia items.
• Advice on assignment of benefit requirements for bulk billed telehealth services available on the Services Australia website.
• Fact sheet available on MBS Online.
• Use this form to claim assigned benefits for electronically transmitted claims.
• These services can be claimed through HPOS Bulk Bill Webclaim capability.
• This form should be used in conjunction with Medicare Bulk Bill Webclaims only.
• General advice on the assignment of benefit process for bulk billed services from the Services Australia website.
• This page contains the latest updates on assignment of benefit requirements and the RACGP’s advocacy on this issue.
• Updates on reforms to the assignment of benefit process available on the DoHAC website.
• This note outlines the rules pertaining to bulk billing and raising additional charges.
• This educational resource provides information on the Medicare requirements for bulk billing and the charging of additional fees to patients.
• Webinar presented by the Department of Health and Aged Care on changes to MBS bulk billing incentives from 1 November 2023. Recorded 24 April 2024.
• Outlines claiming requirements for MBS bulk billing incentive items.
• Bulk billing incentives for eligible patients in Modified Monash Area 1.
• Bulk billing incentives for eligible patients in Modified Monash Area 2.
• Bulk billing incentives for eligible patients in Modified Monash Area 3 and 4.
• Bulk billing incentives for eligible patients in Modified Monash Area 5.
• Bulk billing incentives for eligible patients in Modified Monash Area 6.
• Bulk billing incentives for eligible patients in Modified Monash Area 7.
• This module outlines bulk bill incentive items that are available to medical practitioners.
• identify when you can and can’t charge an MBS bulk bill incentive item
• have an understanding of billing multiple incentives.
• This page provides information on the 1 November 2023 changes to MBS bulk billing incentive payments in general practice, including new tripled bulk billing incentive items.
• This fact sheet covers general eligibility for BBIs, tripled BBI item numbers by level of remoteness and eligible services, standard BBIs (pre-existing items), eligibility scenarios for the new tripled BBIs, and links to further information.
• A collection of news updates on changes to the MBS.
• A collection of fact sheets on changes to the MBS.
• The MBS Review Advisory Committee supports the MBS Continuous Review to ensure the MBS is contemporary, sustainable, evidence-based, and supports universal access to high-value care for all Australians.
• Outlines claiming requirements for MBS items 721 to 732.
• Outlines claiming requirements for MBS items 735 to 758.
• Information for medical practitioners about supporting patients with chronic diseases.
• A flowchart outlining pathways for patients accessing allied health services under a GP Management Plan.
• This module will help you understand your obligations to comply with standard work practices and maintain a sound working knowledge of MBS requirements relating to GP Management Plans.
• This module will help you understand your obligations to comply with standard work practices and maintain a sound working knowledge of MBS requirements relating to Team Care Arrangements.
• This module provides an overview of MBS items for patients with chronic conditions and complex care needs.
• This module provides information on how health professionals may meet to discuss, plan, coordinate or make arrangements on behalf of their patient.

GPMP case studies

The case studies below will help you to understand:

• which patients are eligible for a GP Management Plan (GPMP)
• the steps involved in preparing a GPMP
• the general service limitations of these items and the circumstances where these limitations can be exceeded
• the assistance that practice nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers can provide for GPMP services
• the connection between a GPMP and accessing allied health services.

GPMP case study – Asthma (child) GPMP case study – Asthma (adult) GPMP case study – Osteoarthritis GPMP case study – Tendonitis GPMP case study – Psoriasis GPMP case study – Diabetes

TCA case studies

• which patients are eligible for Team Care Arrangements (TCAs)
• the steps involved in coordinating TCAs
• the assistance that practice nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers can provide for TCA services
• the connection between TCAs and accessing allied health services.
• Information for health professionals about complete medical services, billing multiple MBS items and interpreting common MBS phrases.
• This page provides an overview of what Medicare compliance is and why it’s important, the costs and impacts of non-compliance, who is involved in Medicare compliance, and how to report suspected non-compliance.
• This page provides an overview of who must comply with Medicare obligations, and programs and payments covered by Medicare compliance.
• This page contains links to education and support to help you meet your compliance obligations.
• This module provides an overview of the Medicare compliance program, compliance activities to protect the integrity of Medicare, and resources to help you voluntarily comply and meet your obligations.
• An overview of compliance activities undertaken by the Department of Health and Aged Care.
• If you think you’ve incorrectly claimed a Medicare or practice incentive payment, you must let the Department of Health and Aged Care know as soon as you can.
• You can do this by submitting a voluntary acknowledgement of incorrect payments form.
• This page contains information about the OCP, including links to FAQs and supporting resources.
• The OCP is a secure digital portal for health providers. If you are contacted by the Department of Health and Aged Care about certain Medicare compliance activities, they may also invite you to use the OCP. You can use it to self-review your Medicare claims, identify any potential errors and respond to the Department online.
• You must repay any incorrect payments made to you under Medicare.
• You might also have to pay additional penalties. How you work with the Department of Health and Aged Care can decrease or increase any penalty amount.
• Under the Shared Debt Recovery Scheme, a debt can be split between the practitioner and the person who manages their billing and claiming.
• Information on how to submit a tip-off in relation to billing by a healthcare professional.
• A fact sheet describing the Medicare audit process.
• Use this form to request a review of decision of a compliance audit under subsection 129AAJ(1) of the Health Insurance Act 1973 .

Practitioner Review Program

• An overview of the Practitioner Review Program (PRP), including what constitutes inappropriate practice and how reviews are conducted.
• Information about the purpose of the PRP, how inappropriate practice is identified, how a PRP case is conducted, and participating in the PRP process.
• Information about the PRP interview process.
• Information about the PRP six-month period of review, which may be offered if some or all identified concerns remain after the interview.
• Information about the PRP where practitioners are referred to a delegate of the Chief Executive Medicare after an interview without a six-month period of review.
• Information about the PRP and the review by a delegate of the Chief Executive Medicare.
• Frequently asked questions about the PRP.
• As part of the PRP, you may be given an opportunity to provide a written submission or additional information relating to concerns about your claiming or prescribing.
• A guide to practitioner reviews for persons who employ or otherwise engage practitioners.
• This guide outlines in detail the stages in the PSR process for those who are referred to the PSR.
• The PSR agency administers the PSR Scheme to investigate Medicare-referred cases of possible inappropriate practice relating to Medicare, the CDBS and the PBS.
• Throughout the year, the PSR publishes monthly reports of case outcomes.
• All matters referred to the PSR are treated on their merits and with consideration of individual circumstances.
• These summaries of outcomes, reported in the interests of transparency, are not indicative of a likely outcome in any particular case.

80/20 and 30/20 rules

• A collection of information for practitioners about the prescribed pattern of services (the 80/20 and 30/20 rules).
• Information on the prescribed pattern of service 30/20 telephone rule, including relevant telephone attendance services. The rule was introduced on 1 October 2022. 
• Information about inappropriate practice and prescribed pattern of services (the 80/20 and 30/20 rules) and which professional attendance services apply.
• Information about how a breach of the prescribed pattern of services (the 80/20 and 30/20 rules) is detected and the next steps when an 80/20 or 30/20 breach is found.
• Information on legislative requirements and considerations when there is a breach of the prescribed pattern of services (the 80/20 and 30/20 rules).

Inappropriate practice

• Information on the definition of inappropriate practice and how it applies to practitioners and corporate entities.
• Information on the Department’s role in identifying and intervening with practitioners and corporate entities where potential inappropriate is found.
• Information on the common compliance issues associated with inappropriate practice based on Professional Services Review outcomes.
• Information on how to avoid practicing inappropriately, your responsibilities and sources of information to meet Medicare requirements.
• Outlines claiming requirements for MBS items 31356 to 31383.
• Outlines claiming requirements for MBS items 31245, 31361-31364, 31372, 31373, 31379 and 31380.
• Outlines claiming requirements for MBS items 30023 to 30049.
• A guide to billing skin biopsy, skin lesion treatment and skin flap MBS items.
• This module provides guidance on the appropriate billing of MBS attendance items for assessment and/or treatment of skin lesions.
• It outlines instances where an attendance item can be claimed in addition to an MBS procedural item for the treatment of skin lesions.
• This module provides guidance on the appropriate billing of skin lesion excisions.
• It also contains information on performing local skin flap repair, seeking confirmation of clinically suspected melanoma, and follow-up excision where melanoma is confirmed.
• This module includes extracts from MBS explanatory notes to help you understand the requirements for the treatment of skin lesions, other than by excision.
• plantar warts, solar keratoses, multiple warts and solar skin disease
• the appropriate billing of skin lesion excisions
• situations where an attendance item only can be claimed.
• Outlines claiming requirements for MBS items 90250-90257, 90260-90267, 90271-90278, 92182, 92184, 92186, 92188, 92194, 92196, 92198 and 92200.
• Outlines claiming requirements for MBS items 90250-90257 and 90260-90263.
• Outlines claiming requirements for MBS items 90271-90278, 92182, 92184, 92186, 92188, 92194, 92196, 92198 and 92200.
• Information for medical practitioners about eating disorder treatment and management plans.
• This module provides information for medical practitioners and allied health professionals about eating disorder treatment and management plans.
• You’ll learn about eligible conditions and eligibility criteria, and referrals for psychological and dietetic treatment services.
• A flowchart outlining review and referral pathways for patients with eating disorder plans.
• A flowchart outlining patient eligibility for treatment services under an eating disorder plan.
• Outlines claiming requirements for MBS items 3-4, 23-24, 36-37, 44, 47, 193, 195, 197, 199, 585, 594, 599, 2497-2559, 5000-5067 and 90020-90051.
• This fact sheet provides information on how to account for time taken to communicate with patients (eg those who require an interpreter) when claiming time-tiered MBS items.
• Outlines claiming requirements for MBS items 701, 703, 705 and 707.
• Outlines claiming requirements for MBS item 699.
• Outlines claiming requirements for MBS item 715.
• Rules about billing MBS health assessment items and how to apply them.
• Information on Indigenous health assessments and follow-up services for Aboriginal and Torres Strait Islander patients.
• This guideline outlines what you can do to substantiate the coordination of the development of Team Care Arrangements rendered by eligible medical practitioners for MBS item 723.
• This guideline outlines what you can do to substantiate the preparation of a valid GP Mental Health Treatment Plan rendered by eligible medical practitioners for MBS items 2700, 2701, 2715 and 2717.
• This guideline outlines what you can do to substantiate histopathological proof of malignancy for MBS items 30196, 30197, 30202, 30203 and 30205.
• This guideline outlines how you can substantiate services provided under rights of private practice at public hospital outpatient departments.
• This guideline outlines what you can do to substantiate that a patient attended a service and relates to MBS items such as 23, 36, 104, 5020, 10960 and 8553 that require the patient to be present.
• A guide to using HPOS to generate bulk bill processing and payment reports for Medicare Easyclaim.
• This resource shows you how to access bulk bill payment and processing reports in HPOS. You will be able to view claims that have been successfully submitted and paid, and any claims processed with errors.
• A guide to find and verify your patient’s details using HPOS. Check eligibility, care plans and concessions.
• Information about starting with Medicare as a health professional, including claiming benefits and applying for a provider number.
• Health practitioners must meet certain requirements to bill MBS items under Medicare or prescribe subsidised medicines.
• This page provides information on what is and isn’t covered under Medicare, and support available through other programs.
• MBS Online ( www.mbsonline.gov.au ) is the central hub for information about MBS items. You can search for item numbers and view descriptors and explanatory notes.​​​
• The website also contains news on major changes to the MBS and fact sheets with further information.​​​
• Subscribe here to receive MBS Online update emails.
• This fact sheet provides an overview of the AskMBS email advice service. This advice assists health professionals, practice managers and others to understand and comply with MBS billing requirements.
• This collection of AskMBS advisories will help health professionals, practice managers and others to understand and comply with MBS billing requirements.
• Advice for health providers and other users of the MBS on the interpretation and application of MBS items, explanatory notes and associated legislation, to assist them in billing Medicare correctly.
• A collection of modules that provide an introduction to Medicare.
• This module will provide you with an understanding of the Australian healthcare system and what Medicare covers.
• This module will provide you with an understanding of patient eligibility, the importance of a Medicare card, and how to read the details on a Medicare card.
• This module provides an overview of health professional eligibility and how to apply for a provider or prescriber number from Medicare.
• Item numbers, descriptors, explanatory notes – what do these terms mean? How will knowing about them help you in your everyday work? Find the answers to these questions and more in this module.
• This module explains the difference between referrals and requests, and outlines what constitutes a valid referral for MBS item billing purposes.
• This module explains generic aspects of patient billing and the different claiming and payment options.
• This module provides an overview of MBS primary care items and focuses on selecting appropriate attendance items based on characteristics of the attendance.
• This guide provides an overview of Medicare reason codes used when services are rejected in claims lodged for Medicare benefits.
• Information to help you with Medicare bulk billing. Topics covered include assignment of benefit, additional charges and bulk billing, bulk billing and private billing together, and claiming bulk bill payments.
• There are 10 strategies you should adopt in your practice to identify, manage and prevent the risk of incorrect billing under Medicare.
• The five steps in the toolkit make up a continuous improvement cycle for your practice’s Medicare billing assurance approach.
• Encourage health professionals in your practice to complete the following questionnaire before undertaking a Medicare billing assurance review of your practice. You can track perceptions and attitudes and identity trends to focus on.
• Encourage health professionals in your practice to complete this questionnaire after undertaking a Medicare billing assurance review. You can use the responses to track perceptions and attitudes in your practice and identity areas to focus on.
• These 10 simple tips will help you establish and maintain an effective administrative record keeping system.
• This template is intended to assist practices to develop a customised Medicare billing assurance manual. It contains examples of policy statements and operational guidance.
• This Medicare billing assurance charter sets out the principles that support billing activities under Medicare.
• This template helps practices develop a Medicare billing assurance manual. The manual can be customised to suit the particular requirements of each practice. It contains examples of policy statements and operational guidance which can create a Medicare billing assurance approach.
• Public patients in a public hospital receive services free of charge. However, patients may elect to be a private patient and claim Medicare benefits instead.
• To ensure appropriate billing, you need to know when patients can claim Medicare benefits when they attend a public hospital.
• These FAQs answer commonly asked questions on public hospital funding for public patients, and appropriate Medicare billing for private patients in public hospitals.
• consultation services in public hospitals
• exercising rights of private practice
• services provided under rights of private practice at outpatient departments.
• Outlines claiming requirements for MBS items 900 and 903.
• Outlines claiming requirements for MBS items 2700, 2701, 2712, 2713, 2715 and 2717, and is also applicable for video and phone equivalent MBS items 92112, 92113, 92114, 92115, 92116, 92117, 92126 and 92127.
• Outlines claiming requirements for MBS items 2721, 2723, 2725, 2727, 91818, 91819, 91842 and 91843.
• Outlines claiming requirements for MBS items 2739, 2741, 2743, 2745, 91859, 91861, 91864 and 91865.
• The Better Access initiative gives Medicare rebates to help people access mental health professionals and care, regardless of where they live. Find out how the initiative works, who is eligible and how people can access supports.
• Information about services eligible health professionals can provide to patients under the Better Access initiative.
• Find out more about MBS item numbers used for the provision of primary mental healthcare. This page includes common questions and answers obtained from various sources, such as the Australian Psychological Society (APS) and the Department of Health and Aged Care.
• This module provides information about the Better Access to Psychiatrists, Psychologists and General Practitioners (Better Access) initiative in the MBS.
• A flowchart outlining pathways for patients accessing allied health services under the Better Access initiative.
• Outlines claiming requirements for MBS item 10987.
• Outlines claiming requirements for MBS item 10997.
• Outlines claiming requirements for MBS item 10983.
• Information about how to claim services provided by a practice nurse on behalf of a medical practitioner.
• This module provides information on how to claim services provided by a practice nurse on behalf of a medical practitioner.
• A list of practice nurse MBS items. These services are provided on behalf of a supervising medical practitioner. The items are billed using the medical practitioner’s provider number.
• This fact sheet lists examples of how MBS item 10997 can be claimed by medical practitioners. It is intended for patients with chronic or terminal medical conditions who need access to ongoing care.
• This tool allows RACGP members to enter fees for services they provide. The tool will calculate the patient out-of-pocket amount based on the Medicare rebate. Users can also create custom lists of items they use in their practice. You will need to log in to the RACGP website to access this resource.
• This page provides updates on major changes to the MBS affecting GPs, such as the introduction of new item numbers.
• This statement outlines the RACGP’s position on Medicare interpretation and compliance processes. You will need to log in to the RACGP website to view this page.
• resources available to support MBS use and interpretation
• how to ensure your use of the MBS is compliant
• understanding your billing profile – how to find information about your billing profile from common practice software systems
• RACGP resources to assist with MBS use (eg MBS online tool).
• This document provides written responses to questions asked by attendees at the above webinar.
• This document provides written responses to questions asked by attendees at the Demystifying Medicare session held at the RACGP’s 2023 Practice Owners National Conference. This session was presented by Dr Robert Menz and Brett McPherson.
• This webinar is a joint presentation between the Department of Health and Aged Care and the Professional Services Review on the Medicare compliance process. It aims to alleviate some of the fear and misconceptions that exist around compliance.

Q&A – Unpacking the Medicare compliance process

• Frequently asked questions on the Medicare compliance process, designed to help GPs better understand the different types of compliance activities and alleviate some of the fear and misconceptions that currently exist.
• This note explains what is meant by ‘adequate’ and ‘contemporaneous’ records.
• These guidelines provide useful information and tools to support good administrative record keeping within your practice.
• This comprehensive guide provides information about Medicare Indigenous health services.
• This module provides an overview of the benefits of Medicare enrolment and identification for Aboriginal and Torres Strait Islander patients for participation in the Medicare program and their access to better health services.
• This case study illustrates how health professionals can provide primary and preventive healthcare to support managing chronic conditions for Aboriginal and Torres Strait Islander patients under Medicare.
• This case study illustrates how health professionals can provide access to mental health services for Aboriginal and Torres Strait Islander patients under Medicare.
• This case study illustrates how practices can provide primary and preventive care to support better health outcomes for Aboriginal and Torres Strait Islander patients managing asthma conditions.
• This module provides an overview of MBS services available for practices providing primary and preventive care to support better health outcomes for Aboriginal and Torres Strait Islander patients.
• This case study illustrates how health professionals can provide telehealth services for Aboriginal and Torres Strait Islander patients under Medicare.
• This module provides an overview of the QAAMS Program.
• This module explains the key MBS requirements for claiming services provided by an Aboriginal Health Worker, including services provided on behalf of medical practitioners.
• This module explains the key MBS requirements for claiming services provided by an Aboriginal and Torres Strait Islander Health Practitioner, including services provided on behalf of medical practitioners.
• This module provides an overview of the CTG PBS Co-payment Program.
• Help your patient get the Medicare services they need by performing these eight simple checks.
• QAAMS point-of-care testing provides access to on-site testing at the time of a patient consultation for three specific diabetes related tests.
• A flowchart outlining the steps involved in completing an Aboriginal and Torres Strait Islander health assessment.
• A flowchart outlining primary care pathways for Indigenous patients.
• Information about referring a patient for health assessment follow-up services when circumstances change.
• A list of Aboriginal Health Worker MBS items.
• A list of Aboriginal and Torres Strait Islander Health Practitioner MBS items.
• Information on how to register patients for the Practice Incentives Program (PIP) Indigenous Health Incentive.
• Information on how to apply for the PIP Indigenous Health Incentive through HPOS.
• Information on how to register a patient for the PIP Indigenous Health Incentive online through HPOS.
• Information on how to search for a previously registered patient in the PIP Indigenous Health Incentive through HPOS.
• Information on how to withdraw a practice from the PIP Indigenous Health Incentive through HPOS.
• Information on how to withdraw a patient from the PIP Indigenous Health Incentive through HPOS.
• Outlines claiming requirements for MBS items 139 and telehealth equivalent 92142.
• This note provides a list of eligible disabilities for the purposes of claiming MBS items 139 and 92142.
• This module provides information about MBS items supporting early diagnosis, assessment and treatment for patients with a disability or complex neurodevelopmental disorder.
• A flowchart outlining MBS services available to patients with an eligible disability.
• Where a practitioner provides a number of services (excluding operations) on the one occasion, they can choose to bulk bill some or all of those services and privately charge a fee for the other services, in excess of the Medicare rebate.
• This note contains more information on the rules pertaining to split billing.
• Information on the Services Australia website about split billing.
• These fact sheets provide information about ongoing MBS telehealth arrangements.
• This fact sheet provides information about the prescribed pattern of service (30/20) rule for phone services introduced on 1 October 2022.
• Information and advice for GPs and other medical practitioners about the COVID-19 MBS telehealth established relationship requirement, including clarification of exemptions.
• It is a legislative requirement that GPs and other medical practitioners working in general practice must only perform a telehealth or telephone service where they have an established clinical relationship with the patient.
• AskMBS advisory clarifying exemptions from the established clinical relationship requirement for MBS general practice telehealth services.
• Outlines claiming requirements for MBS items 93644, 93645, 93653, 93654, 93660, 93661, 90005 and 10660.
• Information about billing MBS attendance items for immunisations.
• Information on MBS COVID-19 vaccine suitability assessment services from 1 February 2023.
• This page includes links to frequently asked questions about MBS COVID-19 vaccine items and scenarios to assist with correct billing.

Advertising

• Rejected Items
• Patient Claiming
• Notes on Bulk Bill/DVA Claims
• Checklist for Installing Medicare Online
• Online Claiming Error Messages
• Online Patient Verification