Notification of Upcoming Compliance Activity – Inappropriate Claiming of Urgent After-hours Items
The Department of Health and Aged Care is responsible for ensuring the integrity of Australian Government health programs through the prevention, identification and treatment of incorrect claiming, inappropriate practice, and fraud.
The Department of Health is currently reviewing compliance risk relating to possible inappropriate claiming of Medicare Benefit Schedule (MBS) items for Urgent After-hours Attendances (items 585, 588 and 591), and Urgent After-hours Attendances during Unsociable Hours (items 599, 600).
The department recognises there are individual providers who may specialise in the provision of after-hours services to the community, who are therefore, as expected, claiming a high percentage of after-hours items. However, due to the specific requirements for urgent after-hours items set out in division 2.14 of the Health Insurance (General Medical Services Table) Regulation 2021, a high ratio of urgent to non-urgent after-hours items may suggest non-compliance. Due to the observed volume and proportion of the items being claimed, the department is concerned that some providers may not be meeting full MBS item descriptor requirements.
A targeted letter will be sent to identified practitioners and is a self-assessment approach used to support early intervention and education. Letters will be accompanied by a claiming factsheet to assist providers in their self-assessment and understanding of MBS requirements.
