Medicare compliance activities in 2025
9 April 2025
ASA leaders recently met with Medicare compliance officers from the Department of Health and Aged Care to discuss upcoming priorities in relation to sleep medicine item numbers.
It was noted that compliance priorities for 2025 include a focus on specialist and consultant physician claiming of attendance items and management plans, particularly related to MBS items 132 and 133, as well as claiming MBS services while the provider is overseas.
The department has raised concerns with the ASA about the potential for incorrect billing of item numbers 132 and 133, noting that the department reports significant growth in these item numbers across all specialties, including sleep medicine. We have asked the department to provide more specific communication regarding their concerns about billing patterns and planned compliance activities. When this information is provided to us, we will circulate it to the membership. In the meantime, we encourage members to ensure that all components of an item number are met when billing for MBS services.
It is also important for ASA members to understand that all components of an MBS service must be performed in Australia. For telehealth consultations, this means that both the doctor and the patient need to be in Australia at the time of the consultation. With respect to sleep studies, a patient can undergo a sleep study whilst the reporting physician is overseas, but the department made it clear that that the reporting of the study must take place when the physician is in Australia. Government data matching may potentially link sleep studies being performed while the physician is outside Australia and unfortunately there is no way for data matching to record the date the report is completed. Therefore, it is important that sleep physicians keep accurate records so that they can easily justify a claiming pattern if needed. The overnight investigation of sleep must be performed under the supervision of a qualified adult sleep medicine practitioner. This individual may be the same or a different individual to the practitioner who interprets the data and prepares a report. Supervision from outside Australia is not acceptable.
Following on from this, the conversation outlined the department’s risk-based and proportionate approach to compliance, with a strong emphasis on prevention and education, and where enforcement action is taken based on the seriousness and scale of the identified behaviour.
More details are available from the recent ASA webinar Medicare compliance - getting it right from the start. The department is still working on formulating responses to the outstanding queries from members before, during and after the webinar.
In the meantime, the department has also developed the Understanding Medicare: Provider Handbook. This resource is a plain English guide that details the fundamental elements and principles of Medicare. It provides core guidance for healthcare professionals and others navigating the Medicare system.
The department provides a range of educational resources and support to help you meet your legal obligations as a health practitioner and reduce the risk of incorrect billing under Medicare. Learn more
Questions about this topic should be directed to the CEO, Marcia Balzer.