GP reprimanded and ordered to pay $455,000 for Medicare billing breaches

Doctors who make Medicare claims for services need to keep an adequate and contemporaneous record to demonstrate they provided the service and that the service satisfied all the elements of each MBS item number. Failing to keep the necessary records can result in professional and financial consequences including being ordered to repay the claimed benefits in full and suspension of billing rights as this case illustrates. 

Medical records and documentation – Medicare 

Dr I was referred to a Professional Services Review Committee (the committee) over his billing of multiple Medicare Benefits Schedule (MBS) item numbers. The item numbers primarily related to long consultations, health assessments and specific mental health items numbers (in particular items 36, 703, 705, 715, 721, 732, 2713 and 2717). 

Following a hearing where a sample of Dr I records were examined, the committee determined that in almost all cases his records were inadequate to support his billing of the item numbers. The records: 

• lacked sufficient detail to allow another practitioner to understand what had occurred in the consultation 
• did not justify the billing of a separate service, such as a mental health service (item 2713) – where the consultation record only showed a presenting complaint and a prescription 
• frequently appeared to have been copied from templates and included findings from examinations that were unlikely to have been performed and no individual patient information 
• did not support the patient’s eligibility for assessment services (items 703 or 705) 

Where Dr I had billed for services such as health assessments and management plans, required documentation had either never been completed or was inadequate. Reports often lacked clinical detail, and many appeared to have been completed from templates and in the patient's absence. 

MBS item numbers 

In addition to the lack of documentation, the committee also found Dr I had billed item numbers for patients who were ineligible for the services and with no attempt to check the patient’s eligibility. 

Dr I was reprimanded and counselled.  

He was ordered to repay $455,319.28 to the Commonwealth and disqualified from billing: 

• MBS item 36 for three months, and 
• MBS items 703, 705, 715, 721, 732, 2713 and 2717 for 12 months. 

Ensure you understand the requirements of each MBS item number you bill. This includes: 

• ensuring your consultation meets all MBS item requirements 
• documenting sufficient detail in the medical record to demonstrate your compliance with the MBS item descriptor 
• maintaining contemporaneous medical records.  

Your records should clearly identify the patient and include detailed entries for each service, allowing someone else to understand why the service was needed, the clinical input you provided, and why a particular item number was billed. Any care plans, management plans, or assessments must be carefully documented and tailored to the patient, completed with their input and documented in their medical records. Make sure to include the patient’s agreement, offer them a copy, and ensure their presence—whether in person, by phone, or video— depending on the specific MBS item number requirements. 

Avant resources: Medicare-what you need to know 

Avant factsheet: Medical records- the essentials 

Department of Health: AskMBS Email Advice Service

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.