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Medicare Australia

What is Medicare Australia?

Medicare Australia is an Australian Government agency that is part of the Department of Human Services portfolio. It administers a number of Australian Government health programs including the PBS, Medicare Benefits Scheme (MBS), the Australian Childhood Immunisation Register (ACIR), and a range of associated government programs.

Some examples relating to PBS administration include:

  • Processing and payment of PBS prescriptions from approved pharmacists, approved hospital pharmacies and approved medical practitioners.
  • Processing and payment of Repatriation prescriptions on behalf of the Department of Veterans' Affairs.
  • Processing of Safety net cards.
  • Approval of authority prescriptions.
  • Providing PBS stationery - PBS prescriptions to doctors, Safety net card application forms to approved pharmacists.

Functions of Medicare Australia

In administering these programs, Medicare Australia processes more than 400 million transactions each year and pays benefits in excess of $16 billion. The major recipients of payments are:

  • Doctors and allied health workers who provide health services to the Australian community.
  • Pharmacists who supply PBS subsidised medicine to the Australian community.
  • Consumers who seek reimbursement from Medicare Australia for the range of medical and pharmaceutical services subsidised by the Australian Government.
  • Health funds claiming private health insurance rebates.

Ensuring the integrity of the PBS

An important part of Medicare Australia’s role is to maintain the integrity of the programs and services it administers, including the PBS, and to ensure that they are being used appropriately by medical practitioners, pharmacists and consumers.

In recent years, PBS expenditure has increased at rates faster than general health expenditure. Drivers for this growth include the introduction of new, higher cost medicine and the increasing consumer expectations around the availability of subsidised medicine.

To ensure that payments of benefits are correctly made for services legitimately rendered, Medicare Australia uses a range of strategies to prevent, detect, and investigate inappropriate practice and fraudulent behaviour. These include a combination of:

  • Research, analysis of data and intelligence, and audits, including comprehensive post-payment audits, to identify areas at high risk of non-compliance.
  • Education and communication activities to inform and encourage compliance with legislative requirements by all prescribers, pharmacists and health consumers.
  • Direct interventions with prescribers, pharmacists and health consumers of concern. Depending on the nature and significance of the non-compliance, Medicare Australia undertakes:
    1. Targeted feedback: e.g. where there is an unusually high level of PBS prescribing of a particular PBS restricted or authority required medicine, a letter may be sent to a medical practitioner to remind them of the PBS restrictions criteria for that medicine and that they must, when prescribing that medicine on the PBS, prescribe in accordance with the PBS restrictions criteria.
    2. Interviews: e.g. a pre-arranged visit from a Medicare Australia Compliance Pharmacist or Medical Adviser when a medical practitioner’s prescribing profile is different from that of their peers or if the practitioner's prescribing of a particular PBS restricted or authority required medicine continues to suggest it is being prescribed outside the PBS restrictions criteria.
    3. Recovery of payments: e.g. recovery of payments made to pharmacists for inappropriate PBS claims.
    4. Investigations: e.g. investigating suspected cases of fraudulent behaviour against the PBS and referral to the Commonwealth Director of Public Prosecutions for criminal prosecution where fraudulent behaviour is detected.
    5. Peer review: Professional Services Review (PSR) is an independent statutory authority that examines health practitioners’ conduct in potential cases of inappropriate practice when requested by Medicare Australia.

Medicare Australia undertakes these strategies to help ensure doctors, pharmacists and consumers meet the requirements for the Health Insurance Act 1973, National Health Act 1953, and the Medicare Australia Act 1973.

The Compliance Plan for Medicare Australia for 2005-6 is available on line at www.medicareaustralia.gov.au/providers/program_review_integrity/Compliance.htm.