Medicare & Billing Compliance

What Medicare billing compliance means

Medicare billing compliance is about claiming correctly and being able to prove it. Every claim a practice makes is a statement that a specific service was provided, to an eligible patient, by an eligible provider, and that it meets the descriptor of the MBS item billed. The system pays first and checks later, which is why the real compliance work is in the records behind the claim, not the claim itself.

The stakes are high because Medicare income is recoverable. If a service did not meet the item requirements, the benefit can be clawed back, sometimes years later and at scale, and serious or repeated problems escalate to the Professional Services Review. Good billing compliance is simply the habit of billing what you can defend.

The framework at a glance

The MBS: the rulebook for what you can claim

The Medicare Benefits Schedule is the source of truth for billing. Each item has a descriptor that sets out exactly what must be done, by whom, and often for how long, before the item can be claimed. Billing an item whose descriptor was not fully met is the most common compliance failure, and it is rarely deliberate: it usually comes from habit, template note-taking, or misreading a time tier.

Item descriptors also change. The MBS is updated regularly, and practices need a way to catch the changes that affect their billing.

In-depth guideMBS March 2026: Patient-End Support, ECG 11714, Health Assessments

Bulk billing and assignment of benefit

A service is bulk billed when the patient assigns their Medicare benefit to the provider and the provider accepts it as full payment, charging no gap. That assignment is the assignment of benefit, and capturing it correctly is a compliance requirement in its own right, not a formality.

The mechanics are changing: digital SMS and web consent is replacing the paper assignment form, with rules about when consent must be captured and how long it must be retained. Get the consent process right and the rest of bulk billing follows.

In-depth guideMedicare Assignment of Benefit: What Changes on 1 July 2026

The incentive programs: PIP, BBPIP, MyMedicare, and ePIP

A large share of practice income now flows through incentive programs, and each has its own conditions that must be met continuously, not just claimed:

• The Practice Incentives Program (PIP) rewards accredited practices for quality and capacity activities, several of which scale with your SWPE.
• The Bulk Billing Practice Incentive Program (BBPIP) adds a loading for practices that bulk bill every eligible service, tracked quarterly.
• MyMedicare registration unlocks chronic-condition, telehealth, and BBPIP items, but carries its own enrolment and record-keeping duties.
• The ePIP eHealth incentive requires uploading shared health summaries to a quarterly quota, with clawback for non-compliance.

The common thread: each incentive is conditional, and the conditions are auditable. Accreditation underpins all of them, which is why RACGP accreditation sits beneath this whole pillar.

In-depth guideBulk Billing Practice Incentive Program (BBPIP) Compliance Guide

Telehealth, mental health, and DVA billing

Several billing streams have their own rule sets layered on top of the MBS:

• Telehealth items carry eligibility rules, including the MyMedicare and established-relationship requirements. See telehealth Medicare billing compliance.
• Mental health billing under Better Access and the Mental Health Treatment Plan changed after the November 2025 overhaul. See Better Access mental health billing.
• DVA billing for veterans runs on its own fee schedules and integrity rules. See DVA fee changes.

In-depth guideTelehealth Medicare Billing 2026: New MBS Items, 80/20 Rule, MyMedicare

How Medicare enforces compliance: audits, the 80/20 rule, and the PSR

Enforcement runs on a spectrum. Services Australia conducts compliance audits of claims and can recover incorrectly paid benefits. The 80/20 rule is a specific trigger: providing 80 or more professional attendances on each of 20 or more days in a year is deemed a prescribed pattern of services and is referred automatically. At the serious end sits the Professional Services Review (PSR), which judges whether a practitioner engaged in inappropriate practice and can require significant repayments.

In 2026 the PSR has been focused on non-individualised care plan templates, where the same wording is reused across patients. For the current enforcement trends, read the PSR guide; for how the rule itself works, read the 80/20 explainer.

In-depth guidePSR Compliance 2026: Care Plan Template Risk and Six-Figure Repayments

What is changing on 1 July 2026

Medicare billing rules shift every year, and 1 July 2026 brings indexation, the digital bulk-billing consent change, and the My Health Record upload mandate, among others. Rather than track them piecemeal, start with the dated roundup hub.

In-depth guideMedicare Changes 1 July 2026: What GPs and Practices Must Know

Common mistakes

• Billing an item whose descriptor was not fully met, often through templated notes or a misread time tier.
• Treating incentive payments as automatic rather than conditional on activities that must be evidenced.
• Weak assignment-of-benefit capture, so bulk-billed claims cannot be defended on audit.
• Reusing care plan wording across patients, the exact pattern the PSR is targeting.
• Missing MBS item changes, so the practice keeps billing a descriptor that has moved.

Frequently asked questions

What is Medicare billing compliance?

Medicare billing compliance is following the rules that govern Medicare claims: billing the MBS item that matches the service actually provided, handling bulk billing and assignment of benefit correctly, meeting the conditions of any incentive programs claimed, and keeping records that can defend each claim if it is audited.

What is the 80/20 rule?

The 80/20 rule is a Medicare trigger. A practitioner who renders 80 or more professional attendances on each of 20 or more days in a 12-month period is deemed to have a prescribed pattern of services, which is automatically referred to the Professional Services Review. It is a volume safeguard, not a judgement about any single service.

What is the difference between a Medicare audit and the PSR?

A Services Australia compliance audit checks claims and can recover incorrectly paid benefits. The Professional Services Review is a separate body that reviews whether a practitioner engaged in inappropriate practice and can impose repayments and other outcomes. An audit can escalate to the PSR for serious or repeated issues.

Do I need to be accredited to claim Medicare incentives?

Most of the incentive programs, including PIP and the BBPIP loading, require the practice to be accredited against the RACGP Standards. Accreditation is the precondition that unlocks the incentive income, which is why it sits beneath Medicare billing compliance.

How long do we have to keep Medicare records?

Records that support a claim, including the consent behind a bulk-billed service, must be retained for the period set by the relevant rules (for the modernised assignment of benefit, this is a defined retention period). Keep enough to defend any claim if it is audited later.

Last reviewed 20 June 2026