Medicare Billing Compliance: Avoiding Common Pitfalls

The Importance of Medicare Compliance

Incorrect Medicare billing can result in:

• Repayment demands (often substantial amounts)
• Financial penalties
• Referral to the PSR (Professional Services Review)
• Damage to professional reputation
• In serious cases, criminal prosecution

Common Billing Errors

1. Incorrect Item Numbers

• Using item numbers that don't match services provided
• Claiming higher-value items than justified
• Misunderstanding item descriptor requirements

2. Time-Based Items

• Not meeting minimum time requirements
• Inadequate documentation of consultation length
• Billing for time not directly with the patient

3. Bulk Billing Issues

• Failing to collect patient signatures
• Not meeting bulk billing requirements
• Incorrect assignment of benefits

4. Duplicate Billing

• Billing multiple items for the same service
• Claiming for services already included in another item
• Multiple practitioners billing for the same consultation

5. Referral Problems

• Accepting invalid referrals
• Billing without current referral
• Not checking referral validity

Documentation Requirements

Adequate clinical records should include:

• Date and time of service
• Patient identification
• Clinical findings
• Diagnosis or clinical impression
• Treatment provided
• Follow-up plan

Compliance Program Recommendations

1. Staff Training

• Regular billing training for all staff
• Updates when MBS changes
• Clear escalation procedures

2. Internal Audits

• Regular review of billing patterns
• Comparison with peer data
• Random record audits

3. Written Policies

• Billing procedures manual
• Escalation procedures
• Documentation standards

4. Professional Advice

• Seek clarification when unsure
• Engage billing experts for complex items
• Legal review of compliance program

If You're Audited

If Medicare initiates an audit:

1. Contact us immediately
2. Don't respond without legal advice
3. Gather relevant documentation
4. Cooperate fully while protecting your rights

Our Support

We assist practices with:

• Compliance program development
• Staff training
• Audit preparation and response
• PSR matters

Contact us for a confidential compliance review.