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In-depth topic course

Medicare Billing Compliance and the Professional Services Review

Accurate MBS Claiming, Record-Keeping and Responding to Compliance Concerns

  • 3 CPD hoursEstimated learning time
  • 20-question assessmentPass mark 80%
  • Online, self-pacedStart any time
  • CertificateFor your CPD records

Written for

Topics

About this course

Every Medicare claim made under your provider number is a legal claim on public money, and you remain responsible for it even when reception staff, billing software or a practice manager enter it. MBS rules change often, telehealth eligibility depends on details that are easy to miss, and time-based items are only as strong as the notes behind them. Compliance activity starts quietly, with data letters and audit requests, and practitioners who are unprepared can face debts, administrative penalties and, for unusual patterns, review by the Professional Services Review.

This course gives you a practical way to claim accurately and defend your claims. It explains how a Medicare benefit arises in law, how to read item descriptors and explanatory notes as checklists, how to record time and eligibility, and how the Department's audit, debt and penalty processes and the three-stage PSR process work. It then shows you how to respond if a letter arrives and how to build practice systems that keep billing honest under commercial pressure.

It is written for Australian practice, with case illustrations from general practice, specialist rooms and allied health, and it is current to the 1 November 2025 changes to MyMedicare-linked telehealth and Better Access items.

Written and reviewed by

Written by

Dr Hannah Whitmore PhD, MSc, RN

Nursing Education & Professional Practice

Reviewed by (legal reviewer)

Professor James Ellington LLB, LLM, PhD

Healthcare Law, Ethics & Professional Regulation

Reviewed by (editorial team)

Editorial Team Member

Healthcare ethics, professional conduct, patient safety and evidence-based education.

Last reviewed

Our authors and reviewers check course content for accuracy and currency. Completing a course does not guarantee any particular outcome with Ahpra, a National Board, a tribunal or an employer.

Who this course is for

  • GPs and other medical practitioners who bill MBS attendance, telehealth or chronic condition items
  • Specialists and consultant physicians managing referrals, procedures and same-day rules
  • Practice principals, owners and clinical directors responsible for billing policy
  • Allied health practitioners claiming Medicare items under chronic condition or Better Access referrals
  • Practitioners who have received a Medicare data letter, audit request or PSR correspondence
  • Practice managers and senior reception staff who support clinicians with claiming
  • Overseas-trained and early-career practitioners new to Australian Medicare billing

What you’ll learn

  • Claim accurately

    Select items after the service based on what you did and how long it took, and check telehealth, co-claiming and referral requirements before claiming.

  • Write claim-ready notes

    Keep contemporaneous records that show each element of the item claimed, including duration and eligibility, without relying on templates or copy-forward.

  • Respond to compliance contact

    Read and diarise compliance letters, get advice early, review your claims honestly and use voluntary acknowledgement where it applies.

  • Understand the PSR

    Explain inappropriate practice, the 80/20 and 30/20 rules, section 92 agreements and Determining Authority sanctions, and how to avoid getting there.

Learning objectives

  • Explain the legal conditions that must be met before a Medicare benefit is payable and why the provider remains responsible for every claim.
  • Read an MBS item descriptor and its explanatory notes as a checklist, including time-based, co-claiming and referral requirements.
  • Apply current telehealth eligibility rules, including the established clinical relationship, MyMedicare pathways and documented exemptions.
  • Write clinical records that show each element of the item claimed, including duration where time matters.
  • Describe Medicare compliance activity, including audits, notices to produce, debts, administrative penalties and voluntary acknowledgement.
  • Explain the PSR scheme, the 80/20 and 30/20 prescribed patterns, section 92 agreements and Determining Authority sanctions.
  • Respond to a compliance letter promptly, honestly and with appropriate advice.
  • Build practice systems and a personal billing integrity plan that keep claiming accurate under commercial pressure.

Scenarios covered

Practice situations you reason through, step by step, in the course.

  • The rounded-up consult

    A GP habitually bills the 20-minute tier for 15 to 18-minute consults booked in 20-minute slots. You work through why slot length is not service time, how to record duration, and what to do about past claims.

  • The telehealth patient you haven't seen for 14 months

    A long-standing patient requests a video consult but has not been seen face to face for over a year and is not registered in MyMedicare. You test the eligibility pathway and decide what can be claimed.

  • The practice billing target

    A new contractor is told his chronic disease billing is below target and that colleagues bill long consults for every review. You practise a response, the records to keep and when to call your MDO.

  • The notice to produce

    An audit letter asks for records supporting a selection of claims within a set deadline. You map the first 48 hours, the honest review of your own claims and the decision about voluntary acknowledgement.

  • Close to the 80/20 line

    A busy outer-suburban GP bills more than 80 services on many days because extra items are added to visits. You learn how the prescribed pattern rule counts services and what exceptional circumstances mean.

  • The nurse-delivered follow-up

    A manager suggests billing practice nurse reviews as GP consultations. You check when services provided by others can be claimed and how to say no clearly.

Course contents

8 sections, 35 lessons, then the final assessment.

  1. Section 1: How Medicare Works and Who Is Responsible4 lessons
    • 1.1 The Legal Basis of a Medicare Benefit
    • 1.2 Your Provider Number, Your Responsibility
    • 1.3 Billing Models: Bulk Billing, Patient Claims and Gap Fees
    • 1.4 The Professional Code Behind the Money
  2. Section 2: Reading and Applying MBS Item Descriptors5 lessons
    • 2.1 Anatomy of an Item Descriptor
    • 2.2 Time-Based Attendances and the Clock
    • 2.3 Co-Claiming, Same-Day Rules and Aftercare
    • 2.4 Referrals and Requests
    • 2.5 Getting Answers: Explanatory Notes, AskMBS and Written Advice
  3. Section 3: Telehealth, Chronic Condition and Team-Based Items4 lessons
    • 3.1 Telehealth: The Established Clinical Relationship and MyMedicare
    • 3.2 Phone Versus Video and the 30/20 Rule
    • 3.3 Chronic Condition Management, Health Assessments and Mental Health Items
    • 3.4 Services Provided by Others on Your Behalf
  4. Section 4: Records That Support Every Claim4 lessons
    • 4.1 Adequate and Contemporaneous Records
    • 4.2 What a Claim-Supporting Note Contains
    • 4.3 Templates, Copy-Forward and Late Entries
    • 4.4 Records for Specific Item Types
  5. Section 5: How Medicare Compliance Activity Works5 lessons
    • 5.1 The Compliance Landscape
    • 5.2 Data Analytics, Letters and Practitioner Review
    • 5.3 Audits and Notices to Produce
    • 5.4 Debts, Administrative Penalties and Voluntary Acknowledgement
    • 5.5 Shared Debts, Review Rights and Fraud
  6. Section 6: The Professional Services Review Scheme5 lessons
    • 6.1 Inappropriate Practice and the Peer Standard
    • 6.2 The 80/20 and 30/20 Prescribed Patterns
    • 6.3 Stage 1: The Director's Review and Section 92 Agreements
    • 6.4 Stages 2 and 3: Committee and Determining Authority
    • 6.5 PBS Prescribing, Corporate Entities and Links with Ahpra
  7. Section 7: Responding Well to a Compliance Concern4 lessons
    • 7.1 The First 48 Hours: Read, Diarise, Get Advice
    • 7.2 Reviewing Your Own Claims Honestly
    • 7.3 Writing a Response and Meeting Reviewers
    • 7.4 Looking After Yourself
  8. Section 8: Building a Compliant Practice4 lessons
    • 8.1 Practice Governance and Billing Policies
    • 8.2 Training, Auditing and Feedback Loops
    • 8.3 Practice Owners, Contracts and Pressure to Bill
    • 8.4 A Personal Billing Integrity Plan
  9. Final assessment and written reflection20 questions

Assessment and certificate

  1. Work through the course

    Study each section at your own pace, including the case illustrations and apply-it questions.

  2. Pass the assessment

    20 scenario-based questions. You need 16 correct (80%) to pass.

  3. Write your reflection

    A short written reflection on how the learning applies to your own practice.

  4. Download your certificate

    Shows your name, the course, the date and 3 CPD hours. Anyone can check it on our verification page.

What you keep for your CPD records

  • A certificate of completion recording approximately 3 CPD hours of estimated learning time
  • A written reflective account on your own billing risks and the changes you will make
  • A one-page pre-claim checklist and a 48-hour response plan for compliance letters
  • A model personal billing integrity plan you can adapt for your practice

How certificates and CPD records workVerify a certificate

Primary sources

The course is built on these official documents. Check them for the current version.

Questions about this course

Does Ahpra accredit or approve this course?

No. It is an independent educational course. It is not accredited, not approved and not endorsed by Ahpra, any National Board, the Department or the PSR. Under your Board's CPD standard you decide whether it is relevant to your CPD plan and record the time you actually spend.

Who is responsible if a billing error was made by reception staff?

The practitioner whose provider number is on the claim is responsible for it. A debt may be shared with an entity that managed billing in some cases, but you should check claims made in your name and make sure staff and software follow a clear billing policy.

What is the 80/20 rule?

It is a prescribed pattern under the PSR scheme: rendering 80 or more relevant services on each of 20 or more days in a 12-month period. It leads to a referral to the Director of PSR unless exceptional circumstances apply. A separate 30/20 rule applies to phone services.

What should I do if I receive a Medicare audit letter?

Read it carefully, diarise every deadline and contact your medical defence organisation or insurer the same day. Gather the records requested, review your claims honestly, never alter records, and respond factually and on time. The course sets out a step-by-step plan.

Can I avoid a penalty by owning up to incorrect claims?

Departmental guidance states that no administrative penalty applies to a voluntary acknowledgement made before compliance action starts, and that cooperation can reduce a penalty during compliance action. Repayment of the incorrect amount is still required.

Does this course cover the November 2025 telehealth and Better Access changes?

Yes. It explains the established clinical relationship, MyMedicare pathways, documented exemptions and the 2025 changes to mental health treatment plan items, and reminds you to check MBS Online for later updates.

Is this course only for GPs?

No. It is most detailed for medical practitioners, but specialists, practice owners and allied health practitioners who claim Medicare items will find the sections on descriptors, records, audits and practice systems directly relevant.

Will completing this course satisfy a PSR, Departmental or Board requirement?

Not by itself. If you have a condition, undertaking or agreement that requires education, confirm with the relevant body, and with your lawyer or MDO, whether this course is acceptable before relying on it.

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