Ethics and professionalism CPD for health practitioners in Australia [email protected]
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Online course · Australia

Medicare Billing Compliance and the Professional Services Review

Accurate MBS Claiming, Record-Keeping and Responding to Compliance Concerns

  • About 3 hours
  • 20 scenario questions
  • Reflective account
  • Certificate of completion
  • Online, self-paced

About this course

Every Medicare claim made under your provider number is your responsibility, even when someone else pressed the button. This three-hour course explains how to read MBS items, document what you claim and respond if Medicare or the Professional Services Review contacts you.

The course starts with the legal basis of a Medicare benefit, why your provider number makes you responsible, billing models from bulk billing to gap fees and the professional code behind the money. It then teaches you to read item descriptors: their anatomy, time-based attendances, co-claiming and same-day rules, aftercare, referrals and where to get answers, including AskMBS.

Telehealth, chronic condition, health assessment and mental health items are covered, together with services provided by others on your behalf. A section on records explains what a claim-supporting note contains and the risks of templates, copy-forward and late entries.

Later sections explain Medicare compliance activity, from data analytics and letters to audits, debts, administrative penalties, shared debts and fraud, then the Professional Services Review scheme from the Director's review to the Determining Authority. The course ends with responding to a compliance concern and building a compliant practice.

What you will learn

  • List what has to be true before Medicare will pay a benefit, and why the provider carries the risk
  • Break an item descriptor into a checklist covering time, co-claiming, aftercare and referral requirements
  • Check telehealth eligibility, including the established relationship rule and documented exemptions
  • Write notes that would show an auditor every element of the item you billed
  • Understand audits, notices to produce, debts, penalties and voluntary acknowledgement
  • Explain the PSR process, the 80/20 and 30/20 patterns and what a section 92 agreement involves
  • Answer a compliance letter on time, honestly and with the right adviser beside you
  • Put billing policies, audits and a personal integrity plan in place in your practice

Who this course is for

  • General practitioners, rural generalists and non-GP specialists
  • Nurse practitioners and other practitioners with a Medicare provider number
  • Practice principals and owners
  • Practice managers and billing staff
  • Practitioners who have received a Medicare compliance letter

How the course works

  1. Enrol online and the course appears under My Courses in your Probity Courses account, ready to open on a computer, tablet or phone.

  2. Work through 8 sections and 35 short lessons in order, at your own pace. Your place is saved in the browser you use, so you can stop and come back.

  3. Use the key points, scenarios and reflection prompts in each section, and write your own notes as you go; they stay with your course pack.

  4. Finish with a 20-question final assessment. You need 16 correct answers (80%) to pass, and you can retake it after a short pause if needed.

  5. Write your reflective account, submit the short feedback form and your completion is recorded. Download a certificate of completion stating the estimated learning time (about 3 hours); record the time you actually spend.

Course content

9 sections · About 3 hours · 20-question final assessment

1How Medicare Works and Who Is Responsible4 lessons
  • The Legal Basis of a Medicare Benefit
  • Your Provider Number, Your Responsibility
  • Billing Models: Bulk Billing, Patient Claims and Gap Fees
  • The Professional Code Behind the Money
2Reading and Applying MBS Item Descriptors5 lessons
  • Anatomy of an Item Descriptor
  • Time-Based Attendances and the Clock
  • Co-Claiming, Same-Day Rules and Aftercare
  • Referrals and Requests
  • Getting Answers: Explanatory Notes, AskMBS and Written Advice
3Telehealth, Chronic Condition and Team-Based Items4 lessons
  • Telehealth: The Established Clinical Relationship and MyMedicare
  • Phone Versus Video and the 30/20 Rule
  • Chronic Condition Management, Health Assessments and Mental Health Items
  • Services Provided by Others on Your Behalf
4Records That Support Every Claim4 lessons
  • Adequate and Contemporaneous Records
  • What a Claim-Supporting Note Contains
  • Templates, Copy-Forward and Late Entries
  • Records for Specific Item Types
5How Medicare Compliance Activity Works5 lessons
  • The Compliance Landscape
  • Data Analytics, Letters and Practitioner Review
  • Audits and Notices to Produce
  • Debts, Administrative Penalties and Voluntary Acknowledgement
  • Shared Debts, Review Rights and Fraud
6The Professional Services Review Scheme5 lessons
  • Inappropriate Practice and the Peer Standard
  • The 80/20 and 30/20 Prescribed Patterns
  • Stage 1: The Director's Review and Section 92 Agreements
  • Stages 2 and 3: Committee and Determining Authority
  • PBS Prescribing, Corporate Entities and Links with Ahpra
7Responding Well to a Compliance Concern4 lessons
  • The First 48 Hours: Read, Diarise, Get Advice
  • Reviewing Your Own Claims Honestly
  • Writing a Response and Meeting Reviewers
  • Looking After Yourself
8Building a Compliant Practice4 lessons
  • Practice Governance and Billing Policies
  • Training, Auditing and Feedback Loops
  • Practice Owners, Contracts and Pressure to Bill
  • A Personal Billing Integrity Plan
9Conclusion, Final Assessment and Reflection4 lessons
  • Conclusion and key points
  • References and quick-reference guide
  • Final assessment (20 questions, 80% pass mark)
  • Your reflective account

Assessment and certificate

  • Certificate of completion stating the estimated learning time (about 3 hours); record the time you actually spend.
  • A written reflective account you can keep with your CPD records.

Questions about this course

What is the 80/20 rule?

One of the prescribed patterns in the PSR scheme. A practitioner who bills 80 or more professional attendances a day, on 20 or more days within any 12 months, is taken to have practised inappropriately unless exceptional circumstances apply. The course explains this rule and the 30/20 rule for phone services.

Can I rely on my practice manager or software to choose item numbers?

No. The provider is responsible for every claim made under their provider number. The course explains how to build checks that keep claiming accurate.

A Medicare audit letter has arrived. What now?

Read it carefully, note the deadlines, seek advice from your defence organisation and review your own claims honestly. A section covers the first 48 hours in detail.

Is this course relevant to allied health providers?

The principles of accurate claiming apply to everyone who bills Medicare, but most examples involve medical attendances. Allied health practitioners will find the records and compliance sections useful.

Can I count this course towards my CPD?

That is your call under your Board's CPD standard: you choose activities that match your scope and the learning needs in your plan. If this course fits, file the certificate of completion, record the time you actually spend and note one change you will make in practice.

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