To ensure PBS claiming practices are compliant, ethical and audit-ready, here’s what every pharmacist should know.
Navigating the legislative and regulatory requirements of the Pharmaceutical Benefits Scheme (PBS) can be challenging. Yet staying informed and compliant is essential to avoid penalties and safeguard public funding.
‘The systems we use to detect non-compliance are continually evolving,’ Karen Prstec, Director of the PBS Compliance Section of the Department of Health, Disability and Ageing, told delegates at the PSA25 session Stay compliant! Your guide to PBS claiming.
‘We don’t rely solely on digital data; we also investigate non-compliance through calls to doctors, patients and pharmacists.’
What are common compliance breaches?
Compliance safeguards the sustainability of the PBS, with pharmacists acting as the ethical gatekeepers of the scheme to ensure public funds are spent appropriately.
While significant fraud is relatively rare, everyday breaches of the National Health Act 1953 and the National Health (Pharmaceutical Benefits) Regulations 2017 are surprisingly frequent.
These include ‘forward dispensing’ – when the pharmacist anticipates the patient coming in and dispenses ahead of request – claiming unused repeats and unauthorised repeats.
Of these, forward dispensing remains the most common – but non-compliant – practice, said Assistant Director of the PBS Compliance Section Hyunji Yoon, who co-presented the session with Mrs Prstec.
‘The dispensed medication then sits on the shelf and, sometimes, when the patient doesn’t collect it, the claim for supply is still submitted.’
If uncollected medications still remain in the pharmacy, pharmacists must cancel those PBS claims, advised Mrs Prstec. ‘You can’t just put the medicine back on the shelf and receive the money, but you would be surprised how many times we see that happening in practice.’
A breach of legislation for claims for unused repeats may occur when a patient changes their treatment, for example. ‘Perhaps the patient is on a certain drug for depression and that doesn’t work so the doctor prescribes a new medicine,’ Ms Yoon said.
‘The patient may keep their prescription at the pharmacy, the pharmacist decides why waste the prescription so pushes it through and claims for payment, although supply did not occur.’
Unauthorised repeats may result from patient requests for additional repeats, which were not authorised by the prescriber and the pharmacist fails to obtain authorisation from the prescriber.
The PBS Compliance Section has also detected cases of claims submitted for medicines removed from circulation. ‘That is a major red flag and supply may result in criminal charges,’ Mrs Prstec said.
She told delegates: ‘At the end of the day the PBS is built on supply. If a medicine hasn’t been dispensed and supplied to a patient – with a valid prescription, in accordance with the medical practitioner’s instructions – then claiming is non-compliant. Those are the very simple foundations.’
What can get your PBS approval cancelled, and worse?
Systemic non-compliance can lead to criminal prosecution and custodial sentences, financial recovery, loss of PBS approval, reputational damage and disciplinary action.
For example, one pharmacy submitted a large volume of claims using the same authority prescription ID and authority approval ID for prescriptions for different patients and medicines.
The heart medicine Entresto, which attracts a PBS benefit of $100.59, was claimed using authority approval ID 04492022 in 2022. That same approval ID was then used to claim cladribine (a high-value medicine worth $29,000 in PBS benefits) for two different patients in 2024 totalling $117,140 in overpayments of PBS benefits. Over a 30-month period, from January 2022 to June 2024, this pattern of misuse resulted in $1.6M in PBS benefits being overpaid to the pharmacy.
‘This case highlights a serious non-compliant behaviour as authority approval IDs are unique to each prescription,’ Mrs Prstec said. ‘This pharmacist had their PBS approval revoked as a result.’
In another case, four pharmacies, all owned by the same pharmacist, submitted PBS claims for the same prescription for the same patient. ‘Interestingly all these duplicated claims were for high-value items with over $1,000 in PBS benefits,’ she said.
Duodopa gel, a high-cost treatment used in advanced Parkinson’s disease that attracts over $5,000 in PBS benefits, was claimed by all four pharmacies each time a patient presented a prescription for supply at one of those pharmacies. The highest claimed medicine by volume of claims and total government repayment amount was the cancer medicine ibrutinib – totalling 23 claims.
‘This behaviour resulted in a total of $607,000 in PBS benefits being overpaid over a 30-month period,’ Ms Yoon said. ‘Duplicate claiming is not only non-compliant, but also deceptive and undermines the integrity of the PBS. So this pharmacist’s PBS approval was revoked.’
How can pharmacists report non-compliance?
Pharmacists who identify genuine errors may voluntarily acknowledge the issue and repay the incorrect amounts. ‘If something doesn’t seem right, pharmacists should consult the legislation or PBS guidelines,’ Ms Yoon advised.
Tip-offs regarding non-compliance can be submitted anonymously by pharmacy staff, patients, or state regulators. Reports can be made to the Provider Benefits Integrity Hotline 1800 314 808 or online via the Department’s Tip-off form.
Providing as much specific information as possible, such as copies of labels or receipts, greatly assists investigations.
Best practice in PBS supply and claiming
- Dispense only from valid, unexpired PBS prescriptions
- Supply according to prescriber instructions
- Adhere to state/territory laws for controlled and restricted drugs
- Cancel claims when supply has not occurred
- Ensure PBS claims are certified and closed properly.
