Medicare benefit not received (EFT dispute) 011-43120010

Before any details about a Medicare benefit can be provided, make sure that the correct claimant is identified and a security check is completed.

There could be multiple reasons why a claimant may not have received their Medicare benefit(s) as claimed. An initial investigation must be undertaken to determine why the claimant may not have received their Medicare benefit at the first point of contact.

Check:

• if the claim for the Medicare service is on the patient’s history
• the status of the Medicare benefit payment (for example paid, held, rejected, or redirected)
• if the correct claimant was selected when the claim was submitted
• if the correct bank account details were used when the claim was submitted

Note: if the claimant involved in the EFT dispute has an active Invest and/or CMBO PIN flag on their account, all EFT disputes must be referred to MPS Assessing.

The Process page contains details if a claimant advises they have received an EFT payment into their bank account and have not lodged a Medicare claim.

Where Medicare benefits have been successfully paid into a bank account but the claimant states that it is not their bank account, add up all payments in dispute (in total) and determine if the EFT dispute is:

• less than $100, or
• more than $100

View Consumer Directory Maintenance System (CDMS) to confirm if there has been 2 other EFT disputes in the previous 12 months.

If the total amount is greater than or equal to $100 or the claimant has had more than 2 disputes in 12 months, determine if the correct claimant was recorded.

The Process page contains details about managing:

• Resolve EFT dispute for benefit amount below $100
• Resolve EFT dispute for benefit amount $100 and over - claimant or third party error
• Dispute for benefit amount $100 and over - agency error
• Resolve EFT dispute for benefit amount $100 and over - MPS Assessing
• Resolve dispute for benefit amount $100 and over - claimant claims bank account details not updated online or active invest flag

If there is suspected fraudulent activity:

• complete an EFT dispute form
• add the comment ‘possible fraudulent payment’
• forward the form to MPS Assessing

View CDMS comments to check whether the claimant has had 2 EFT disputes within the last 12 months. If they have, follow the process for EFT disputes greater than $100.

The agency will repay the claimant at the first point of contact if:

• the EFT dispute is valid
• is not a suspected fraudulent claim
• the claimant has not had 2 previous EFT disputes within the last 12 month period

See Resolve EFT dispute for benefit amount below $100.

Make sure that the disputed bank account details have been end-dated, and record updated or new bank account details if applicable.

Note: no EFT retrievals are undertaken for Medicare benefit amounts totalling less than $100.

Where the total Medicare benefit amount of the dispute is greater than or equal to $100 or the claimant has had 2 previous EFT disputes in the previous 12 months, investigate who is at fault for the incorrect payment.

The ways in which payments can be made incorrectly include:

• Claimant or third party error
• Agency error

Raise an overpayment if it can be determined who incorrectly received the Medicare benefit, and an EFT retrieval should not be undertaken. For example, not notifying change of bank account details due to a change in family circumstances (separation).

If it has been determined that the Medicare benefit was paid to an incorrect bank account because of a claimant error, an EFT retrieval for disputes equal to or greater than $100 can be undertaken by the agency if the claimant requests one.

Complete an EFT dispute form and forward send to MPS Assessing. If the EFT retrieval is unsuccessful where the claimant has provided incorrect information, the agency is not obliged to repay the funds.

The Resources page contains has a link to the EFT dispute form and contact details for MPS Assessing.

Examples of claimant error

If it has been established that the claimant confirmed their bank details:

• by signing a receipt in the Service Centre and the Service Officer has circled the bank details for the claimant to confirm that the bank details were correct
• comments recorded in CDMS that the bank account details had been read back to the claimant and the claimant confirmed bank details recorded were correct
• a signed Medicare claim form from the claimant including bank account details where the EFT payment is to be made
• a signed copy/transfer or enrolment form from the claimant
• a signed bank account details collection form from the claimant

Note: for bank account details updated online, see Bank details updated online.

If the agency made an error when processing the claim or recording bank account details, Service Officers must repay the claim at the first point of contact.

Examples of agency error

• Transposing of bank account numbers
• Processing errors, such as selecting the wrong claimant
• Not updating bank details as per claimant’s instructions on bank detail, claim, enrolment or copy/transfer forms
• Not circling bank details on thermal/printed receipts when claimant is signing at a Service centre
• Not noting in CDMS that when updating bank details the details have been read back for the claimant to confirm

Wrong bank account

If bank account details have been collected by a third party, for example a medical practice, it is the claimant’s responsibility to verify the bank account details are recorded correctly.

The agency will undertake an EFT retrieval for payments made to an incorrect bank account, but the agency will not reimburse funds if the EFT retrieval is unsuccessful.

Wrong patient, claimant or Medicare card

If a medical practice transmits a claim online using the wrong patient, claimant or Medicare card, contact the health professional to get correct details either:

• verbally and note the information received
• by requesting an invoice to be faxed for processing

Child on 2 Medicare cards

If a medical practice transmits a claim online for a child and the child is on 2 Medicare cards, check if the:

• bank details have been recorded for the child
• payment has gone to anyone other than the person identified as the correct claimant, for example the payment has been incorrectly paid to the other parent

If the payment has been paid to someone other than the person identified as the correct claimant, for example, benefit paid to other parent, the claim must be:

• reprocessed with the correct claimant and,
• a debt raised for the person whose bank account details were recorded

In this case, no EFT retrieval or trace is to be carried out by the agency.

The Process page contains details about how to action an incorrect EFT payment where the cause of the incorrect payment was a child being on 2 Medicare cards.

If a determination cannot be made on whether an incorrect payment was due to claimant or agency error:

• the error is deemed an agency error and
• the claimant is to be paid the Medicare benefit

This may occur if the agency no longer has the original document/s.

An EFT retrieval must be requested where the payment amount is over $100 (in total).

Note: this excludes when bank account details have been changed online.

When the claim or an update to bank account details for the claimant is more than 2 years old, investigate:

• if the benefit went into the wrong bank account, and
• whether it was an agency or claimant error

This investigation can include:

• checking Government Direct Entry Service (GDES)
• looking at CDMS bank account history
• checking to see if other payments have been made

Where a determination cannot be made whether it was claimant or agency error as we no longer hold the original document/s, and the investigation could not determine otherwise, the claimant is to be repaid.

For example, bank account details were updated in 2011, no payments can be verified as having been paid into this account as the claimant has since been bulk billed or the patient history has been culled.

An EFT retrieval should be requested where the payment amount is over $100.

The Process page contains instructions to refer EFT disputes to MPS Assessing.

Note: this excludes when bank account details have been changed online.

Where an EFT dispute is being resolved within a service centre, the claimant must complete the bank details collection form. The form is to be added to the Service Officer daily batch work. The page contains a link to the form.

Where new bank details have been provided via telephony, make sure that comments have been recorded in CDMS confirming the bank details have been read back to the claimant to confirm. This will make sure the agency has evidence of the details being verified with the claimant.

See Store, confirm and end date bank account details for Medicare EFT payments.

The Reserve Bank of Australia (RBA) provides the agency with a GDES report identifying details of any Medicare EFT payment failures. These occur if a bank deposit is rejected by the financial institution (account closed or does not exist).

The internal process of the individual financial institution will determine the time that elapses between the agency depositing the funds and when:

• the financial institution accepts and releases the funds to the claimant, or
• rejects and returns the funds to the agency

Financial institutions do not always return benefits to the RBA that cannot be deposited into a bank account. In some cases the financial institutions retain these benefits in their internal suspense accounts. These funds will be identified by a trace request.

Note: the agency deposits funds into a claimant’s bank account according to the information on their records or as per the claimant’s instructions. The claimant’s financial institution will either accept or reject the deposit. If the financial institution rejects the deposit, it is the claimant’s responsibility to make sure correct bank account details are provided and that the account can be used for electronic funds transfers.

GDES report

The GDES report is automatically run and will update the status of the payments listed on the report from PAID to REJECTED and apply the appropriate reason code within the Mainframe BRNA screen.

This then automatically updates the status of the banking details that relate to the payment in CDMS. For example, bank account closed. The bank details in CDMS are not end-dated, but the Status will be updated to reflect the rejection code on the GDES report.

If bank account details are updated in the system after the money is returned to the agency from the RBA, any claims that have rejected in the claiming details will need to be repaid by the Service Officer. The Process page contains more details.

Note: a claim that has redirect showing should not be changed to reject by a Service Officer or the claimant will receive the payment twice.

BRNA has the functionality to allow users to:

• search for a specific EFT payment record
• use BRNE and BRNS screens for a selected EFT payment record

The Process page contains instructions for a BRNA search.

When bank account details have been collected online, Service Officers must try to determine if it was fraudulent activity or claimant error.

Examples of claimant error can include:

• incorrectly transposing bank account details
• not updating their details after a change in family circumstances (separation)
• their previous bank account has closed

If the claimant advises that the bank account details were updated without their knowledge, the dispute is to be referred to MPS Assessing to investigate further. Complete an EFT dispute form adding comments that the claimant is advising the account has been changed without their knowledge.

If MPS Assessing determine there is enough evidence to support the claimant’s statement that the bank account had been updated without their knowledge:

• the agency will repay the claimant, and
• refers the matter to Medicare Payments Integrity (MPI) section to review and refer to compliance for more investigation

If there is not enough evidence, the matter will be referred to the MPI section to review and refer to compliance for more investigation before any decision on repayment to the claimant is made.

For more details, see Medicare suspected fraud and Business Integrity (BI) flags.

The Resources page contains a link to historical information, a list of Bank Reconciliation Electronic Funds Transfer Enquiry (BREFTE) Return (RETN) codes and descriptions, links to Medicare forms and the Services Australia website.

If a health professional has a debt recovery arrangement in place, they may notice that the amount shown on their EFT bulk bill statement is different to the amount actually deposited into their nominated bank account. For example, the health professional’s EFT bulk bill statement may show $100 as being paid by Medicare, but after 20% is taken by debt recovery only $80 will be deposited into the health professional’s nominated bank account.

The Commonwealth department or agency recovering the debt is responsible for notifying the health professional of their debt recovery arrangement, as well as providing all ongoing communication. For this reason, minimal enquiries are expected to be received by Service Officers.

Health professionals or a member of their staff may still contact the agency regarding the discrepancy between their EFT bulk bill statement and the actual amount deposited into their bank account. If this happens, a health professional’s debt recovery information can be viewed in the Provider Directory System (PDS) and Mainframe (CICS).

Note: if a debt has been fully paid the debt instruction will no longer appear in the PDS but the debt recovery history and corresponding agencies will remain in Mainframe (CICS).

There will be no impact or changes to internal adjustments or recoveries processed as a result of the compliance debt recovery system. If a health professional who has had a payment garnished contacts the agency to tell the claim (from which a deduction was taken) was incorrect and they wish to instigate a voluntary recovery, ignore the fact there was a reduced benefit paid and recover the amount paid by Medicare (That is, the full Medicare benefit, as is current process).

Do not discuss details of the debt recovery arrangement (for example how much is being recovered) with the health professional or their staff. Refer the health professional to the relevant department or agency that is recovering the debt.

Automated recovery arrangements are in place to recover debt/s on behalf of the following Commonwealth departments or agencies:

• Australian Financial Securities Authority (AFSA)
• Australian Taxation Office (ATO)
• Cash management (CM/DHS)
• Child Support Agency (CSA/DHS)
• Department of Health and Aged Care (DoHAC)