Medicare Benefits Schedule - Note GN.1.3

Key information on Medicare benefits and billing practices

The Health Insurance Act 1973 stipulates that Medicare benefits are payable for professional services.  A professional service is a clinically relevant service which is listed in the MBS.  A medical service is clinically relevant if it is generally accepted in the medical profession as necessary for the appropriate treatment of the patient. 

Medical practitioners are free to set their fees for their professional service.  However, the amount specified in the patient's account must be the amount charged for the service specified.  The fee may not include a cost of goods or services which are not part of the MBS service specified on the account. 

Billing practices contrary to the Act

A non-clinically relevant service must not be included in the charge for a Medicare item.  The non-clinically relevant service must be separately listed on the account and not billed to Medicare. 

Goods supplied for the patient's home use (such as wheelchairs, oxygen tanks, continence pads) must not be included in the consultation charge.  Medicare benefits are limited to services which the medical practitioner provides at the time of the consultation - any other services must be separately listed on the account and must not be billed to Medicare. 

Charging part of all of an episode of hospital treatment or a hospital substitute treatment to a non-admitted consultation is prohibited.  This would constitute a false or misleading statement on behalf of the medical practitioner and no Medicare benefits would be payable. 

An account may not be re-issued to include charges and out-of-pocket expenses excluded in the original account.  The account can only be reissued to correct a genuine error. 

Potential consequence of improperly issuing an account

The potential consequences for improperly issuing an account are

(a)        No Medicare benefits will be paid for the service;

(b)        The medical practitioner who issued the account, or authorised its issue, may face charges under sections 128A or 128B of the Health Insurance Act 1973.

(c)        Medicare benefits paid as a result of a false or misleading statement will be recoverable from the doctor under section 129AC of the Health Insurance Act 1973. 

Providers should be aware that Services Australia is legally obliged to investigate doctors suspected of making false or misleading statements, and may refer them for prosecution if the evidence indicates fraudulent charging to Medicare.  If Medicare benefits have been paid inappropriately or incorrectly, Services Australia will take recovery action. 

Services Australia (SA) has developed a Health Practitioner Guideline for responding to a request to substantiate that a patient attended a service.  There is also a Health Practitioner Guideline for substantiating that a specific treatment was performed. These guidelines are located on the DHS website. 

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