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In September 2025, the Commonwealth Health Legislation Amendment (Improved Medicare Integrity and Other Measures) Bill 2025 (Bill) received royal assent1.
The Bill reflects yet another wave of changes being made in a response to the independent Review of Medicare Integrity and Compliance undertaken by Dr Pradeep Philip (Philip Review). This note picks up from our previous update on the proposed changes from the Philip review, which can be read here.
The Philip Review was finalised in April 2023 and made findings and recommendations relating to Medicare integrity and compliance to mitigate the losses. It estimated losses between $1.5 and $3 billion annually because of (largely inadvertent) non-compliance with Medicare charging/claim practices.
What are the changes?
The Bill makes changes in relation to:
- Medicare claiming;
- Investigative powers;
- Pharmacy approval processes, delegation of form and Australian Community Pharmacy Authority membership terms;
- Administrative inquiries and recoveries; and
- Restrictions on admission of evidence.
- Medicare claiming
Currently, the maximum timeframe during which bulk-billed Medicare claims and dental services may be made is 2 years. This will now be reduced to 1 year.
These changes seek to reduce the number of incorrect or potentially fraudulent claims being made.
However, the Minister (for Medicare claims) and the Chief Executive Medicare (for dental claims) will continue to have discretion to allow claims to be made after 1 year, where it is appropriate to do so.
Investigative power
The definition of "relevant offence" under the Human Services (Medicare) Act will be broadened to capture a larger number of criminal offences that relate to Medicare fraud, such as money laundering, forgery and identity fraud.
A broadened definition will address any inconsistencies which may arise under the current application of the Human Services (Medicare) Act meaning any consistent with Medicare fraud can be wholly prosecuted.
Pharmacy approval processes
The National Health Act empowers the Minister to, upon application by a pharmacist, approve the pharmacist to supply pharmaceutical benefits from particular premises.
The application process currently involves a 2-stage process which is estimated to take up to 3 months per stage. This timeframe will be amended to reduce the application process with a single stage process of up to 4 months.
If the Minister determines not to approve an application, a further application can now only be made after 12 months of the initial request. Previously, there was no restriction on further applications being made after an unsuccessful application.
Overall, the amendments focus on reducing administrative delays to help foster the community's prompt access to pharmaceutical benefits where an application is approved.
Delegation of form – pharmacy
The National Health Act provides that the Minister may determine the form in which a request to approve a pharmacist (for the purpose of supplying pharmaceutical benefits at a premises) must be made. This function cannot be delegated meaning any changes to the form was required to be approved by the Minister.
The amendments will now give the Minister power to delegate this power and therefore facilitate matters to be dealt with in a timelier fashion.
Australian Community Pharmacy Authority membership terms
The Australian Community Pharmacy Authority (Authority) is an independent statutory body responsible for considering applications for approval to supply pharmaceutical benefits. The Authority's composition and terms of appointment are set out in the National Health Act.
The membership term will be increased to 3 years in an effort to provide greater stability to the Authority and reduce any undue administrative issues or delays.
Administrative inquiries and recoveries
The Health Insurance Act will allow the Chief Executive Medicare to issue a notice requiring a person to give information or documents if there are reasonable grounds to suspect the person has the required material. This applies to all individuals and not just the person under review, such as past and present employers, health authorities and individual practitioners.
The intention of this power is to improve the Chief Executive Medicare's ability to obtain information about potential non-compliance including whether Medicare benefits were not payable and whether a practitioner holds registration or other approvals as required under the Health Insurance Act.
Given the significant loss to Medicare in incorrect and or fraudulent claims, these amendments are principally intended to help recover payments made as a result of (deliberate or inadvertent) non-compliance or fraud.
Restrictions on admission of evidence
The Health Insurance Act presently imposes restrictions on the admission of certain information obtained under the Professional Services Review's (PSR) 'notice to produce powers' as evidence in other proceedings, including proceedings for determining whether a practitioner is able to be registered to practice under the Health Practitioner Regulation National Law.
These existing restrictions will no longer apply to prosecutions relating to a failure to produce documents, proceedings to recover debts, and other non-compliance proceedings. Additionally, there will be no restrictions on documents produced to the PSR and passed onto the Australian Health Practitioner Regulation Agency (AHPRA) or a National Board, and information obtained or generation by AHPRA or a National Board from its own investigation triggered by the PSR process.
Implications
Australia's healthcare system aims to provide affordable, high-quality and accessible health care to all Australians. Medicare, and the various benefits schemes which underpin its existence, is one of the ways the Government achieves this.
Medicare is Australia's health insurance scheme which provides Australians, and some overseas visitors, with free or subsidised health services.
By amending the various Acts that help protect Medicare's integrity, the Bill aims to improve compliance and ensure a more streamlined and efficient operation and review system.
Key takeaways
- Medicare and dental claims will now need to be made within 1 year
- Offences under the Human Services (Medicare) Act relating to Medicare fraud will now capture money laundering, forgery and identity theft
- Applications by pharmacists to supply pharmaceutical benefits will be processed in 1 stage which will take up to 4 months. Additional applications can only be brought after 12 months of the initial request
- Members of the Australian Community Pharmacy Authority will now serve a 3-year term
- Restrictions will be removed on the admissibility of information obtained under the PSR's notice to produce powers as evidence in other proceedings, such as those by AHPRA or proceedings issued under the Health Practitioner Regulation National Law.
Footnote
1 The Bill amends the Health Insurance Act 1973;
Dental Benefits Act 2008; Human Services (Medicare) Act 1973;
National Health Act 1953; Therapeutic Goods Act 1989; and Public
Health (Tobacco and Other Products) Act 2023
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
