🇦🇺Australia

Billing Scope Violations & Over-Claiming Risk

3 verified sources

Definition

Pharmacies billing for DMMR, RMMR, and QUM services without verifying patient eligibility or valid referral pathway face MBS compliance audits. Victoria Pharmacotherapy Policy explicitly states pharmacists cannot charge additional private dispensing/dosing fees for ORT under PBS—violations create liability. Services must align with clinical indication and 12-month frequency rules.

Key Findings

  • Financial Impact: AUD 5,000–50,000+ per audit cycle (typical MBS recovery for ineligible claims: 10–50 services × AUD 180–250 per claim; potential compliance penalty under Health Insurance Act)
  • Frequency: Per compliance audit cycle (annual to triennial); ongoing for each prohibited billing attempt
  • Root Cause: Insufficient eligibility verification before service delivery, lack of PBS/MBS Online Services integration, staff unfamiliarity with state-based restrictions (e.g., Victoria ORT rule)

Why This Matters

The Pitch: Retail pharmacies face AUD 5,000–50,000+ audit recovery liability for ineligible service billing. Real-time eligibility verification (via MBS Online Services) eliminates audit risk and protects pharmacy reputation.

Affected Stakeholders

Pharmacy Owner, Compliance Officer, Billing Administrator, Pharmacist

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Financial Impact

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Current Workarounds

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Methodology & Sources

Data collected via OSINT from regulatory filings, industry audits, and verified case studies.

Evidence Sources:

Related Business Risks

Unbilled or Delayed Medication Management Services

AUD 2,000–8,000 per pharmacy annually (unclaimed QUM base payments: AUD 125/quarter + AUD 12.50 per bed; unclaimed DMMR: AUD 180.65 per eligible patient annually; follow-up services: AUD 56.33–28.16 per service)

Quarterly Arrears Payment Delays & Accounts Receivable Drag

15–30 days A/R cycle extension per pharmacy; estimated working capital drag: AUD 5,000–15,000 annually (based on typical pharmacy MTM revenue AUD 60,000–120,000/year at 30% arrears float)

Billing Method Selection Error (Per-Encounter vs. Monthly Capitated)

AUD 8,000–20,000 annually per pharmacy (estimated from: monthly capitated loss if underestimating patient volumes = lost per-encounter upside; per-encounter loss if over-selecting without coding infrastructure = missed claims from poor documentation)

Documentation & Coding Errors Leading to Claim Denials & Rework

AUD 4,000–10,000 annually per pharmacy (estimated: 5–10% denial rate × 40–80 MTM claims/year × AUD 180–250 per claim × 2 hours rework per denial × AUD 30/hour labor cost)

TGA Enforcement Action & License Revocation Risk

Business closure/license revocation = 100% revenue loss (unquantified in sources; typical community pharmacy revenue AUD 500k-2M+ annually at risk); estimated enforcement investigation cost: AUD 5,000-15,000 in compliance remediation and legal fees

Manual Documentation Bottleneck & Service Capacity Loss

Estimated 15-30 hours/month of pharmacist time at AUD 50-80/hour (fully-loaded cost) = AUD 750-2,400/month per FTE = AUD 9,000-28,800/year per pharmacist; 2-5% revenue leakage due to lost/delayed scripts during manual documentation bottlenecks = AUD 10,000-50,000/year for typical community pharmacy (estimated AUD 1-2M annual turnover)

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