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Compliance – not just an individual responsibility

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Most GPs know that, under the Health Insurance Act, if they engage in inappropriate practice they will be held to account by a Professional Services Review Committee comprised of their peers.

What seems to be less understood is that it is also an offence under the Act if a person or officer of a body corporate knowingly, recklessly or negligently causes or permits a practitioner employed by them to engage in such conduct.

Now that the responsibility for compliance policy has shifted from the Department of Human Services (DHS) to the Department of Health (DoH), it can be expected we will see an increased focus on the forces within a practice that encourage or silently condone inappropriate practice. While it has previously been difficult to assess this, the DoH is moving to make greater use of data analytics and behavioural economics to identify potential problems.

In utilising these tools, the DoH hopes that it will be able enhance the Department’s understanding of how policy impacts compliance, and better identify clusters of divergent billing behaviour. This will also inform compliance feedback, as well as the Department’s education resources and activities.

This shift in focus has in part come about following the findings of the Large Practices Project. This project was undertaken in recognition of the changing nature of general practice, with the increasing shift from small owner-operated medical practices to large corporate medical practices.

The Large Practices Project found that practice managers and staff have more responsibility for billing than expected. Most GPs learn about billing Medicare on the job or via word of mouth, and practice or business protocols affect the accuracy of Medicare billing. It was found that the culture of the practice, rather than its size, can have a significant influence on claiming behaviour.

These findings have reinforced the need for accessible education materials, and for targeted feedback on billing practices. Feedback has to be specific and directly relevant if it is to be valued and truly informative.

Medicare compliance and appropriate billing is not only an issue for each of us individually, but also as a profession. It goes to our professionalism as GPs and, when inappropriate billing practices are allowed to flourish, a knee jerk policy response is often the result, with MBS rules invariably tightened to reduce the risk of inappropriate use of MBS items. The recent restriction on claiming an item 23 with 721 is a case in point.

Thanks to AMA advocacy, practitioners who are unsure about what a MBS items covers or can be claimed for have available at their fingertips an enquiries email and a number of educational resources. Using the email for a MBS interpretation or claiming question ensures you receive the answer in writing, which is handy should a compliance issue on that matter arise. Various education resources are also available at

The AMA will continue to work with the DoH and the DHS to ensure compliance activities focus on supporting GPs and offering meaningful feedback and effective education.

We all know that GPs are very busy, and try to work within the system as they understand it. Punitive approaches don’t work, and compliance breaches are often simply the result of overly complex rules that are difficult to interpret or not reflective of modern clinical practice.