Health provider compliance audits and reviews

Page last updated: 15 December 2016

Audits and reviews


Health insurance Act 1973 and the Dental Benefits At 2008
Health Insurance Amendment (Compliance) Act 2011
Dental Benefits Legislation Amendment Act 2014
Privacy
Disclosure of information


Audits and reviews

We conduct compliance audits and reviews for:
    • Medicare Benefits Schedule (MBS)
    • Pharmaceutical Benefits Scheme (PBS)
    • Child Dental Benefits Schedule (CDBS)
    • Incentives Programs

Health Insurance Act 1973 and the Dental Benefits Act 2008

The Health Insurance Act 1973 includes provisions that outline the way in which we can conduct MBS health provider compliance audits and reviews. The legislation applies to all health professionals, including specialists and allied health professionals, who are able to claim under Medicare.

The Dental Benefits Act 2008 includes provisions that outline the way in which we can conduct Child Dental Benefit Schedule (CDBS) compliance audits and reviews. The legislation applies to all dental practitioners using the CDBS, including dental hygienists, dental therapists, dental prosthetists and oral health therapists who provide a dental service on behalf of a dental provider.

Key features:
  • We can issue a Notice to Produce documents to you, or the person or corporation who has your records. The notice requires you (or them) to produce documents that substantiate professional services. A notice is issued where we have reasonable concern that a benefit has been incorrectly paid.
  • A debt will be raised if a provider does not comply with a notice or if the documents produced do not substantiate the professional services.
  • Civil penalties may be applied if a person who has a health professional’s records does not comply with the Notice to Produce
  • Documents containing clinical information may be provided to one of our medical or dental advisers
  • You can seek a review of a decision on the compliance audit findings.
For MBS compliance audits and reviews only:
  • An administrative penalty applies for unsubstantiated amounts that total over $2,500. This penalty automatically decreases when a health professional voluntarily tells us about incorrectly claimed amounts before we contact them. However, it can be increased if a health professional does not respond to a Notice to Produce
For CDBS compliance audits and reviews only:
  • Provisions of the Professional Services Review can be applied to any CDBS service billed on or after 4 November 2014. This means we can request the Director of Professional Services Review to review suspected cases of inappropriate practice

Health Insurance Amendment (Compliance) Act 2011

The Health Insurance Amendment (Compliance) Act 2011 (the Compliance Act) applies to Medicare benefits paid to all health professionals under Medicare including allied health professionals and specialists.

The Compliance Act is intended to protect the integrity of expenditure under Medicare. The law is not retrospective and only applies to professional services that were provided on or after 9 April 2011.

The Compliance Act amended the Health Insurance Act 1973 in relation to services rendered on or after 9 April 2011. There are changes to obligations and procedures for Medicare compliance audits and reviews for incorrect payments and unsubstantiated services.

The legislation allows us to issue a formal notice for you to produce documents that substantiate your service claims under Medicare. This notice is issued if there is a reasonable concern that a benefit has been paid that exceeds the amount that should have been paid.
The legislation also allows for penalties to be applied for incorrect payments or unsubstantiated services.

It also gives you the ability to request a review of decision for any audit findings determined by a Medicare compliance audit conducted under Section 129AAJ of the Compliance Act.

Dental Benefits Legislation Amendment Act 2014

The Dental Benefits Legislation Amendment Act 2014 became law on 4 November 2014 and amends the Dental Benefits Act 2008 to include provisions that have significantly changed the way we conduct CDBS compliance audits and reviews of dental services.

The legislation applies to all dental practitioners using the CDBS including dental hygienists, dental therapists, dental prosthetists and oral health therapists who can provide a dental service on behalf of a dental provider.

Provisions of the Professional Services Review can be applied to any CDBS service claimed on or after 4 November 2014.

The Professional Services Review is an independent agency responsible for reviewing and investigating the provision of services by a health practitioner, including dental practitioners, to determine whether inappropriate practice has occurred.

Learn more about Professional Services Review on their website.

Find out more about the Child Dental Benefits Schedule (CDBS)

Privacy

We take privacy seriously and have infrastructure and security arrangements in place to safeguard your information and the information of your patients.

Information will be kept for 10 years after a health compliance audit is completed. If the audit is subject to a review of decision or sets legal precedents, disposal of information is not authorised and the information is retained as National Archives. This is in accordance with legislation and current departmental policies.

Personal information collected during a health compliance audit is protected by the stringent security safeguards we currently have in place. These safeguards prevent and detect unauthorised access to personal information. Penalties, including fines and up to 2 years imprisonment, may apply to an employee who breaches their legal obligations.

Personal information collected and held for health compliance audit services is protected by:

Disclosure of information

For the protection of the welfare, health or safety of an individual and the protection of public funds including the investigation of Medicare fraud, the information we collect may be disclosed, as authorised or as required by law.

Your privacy

The Australian Privacy Principles in the Privacy Act 1988 (particularly Australian Privacy Principle 6) gives you the authority to disclose clinical information to us as required or authorised by law.

You don’t have to provide documents containing clinical details unless the information is needed to substantiate a service. The type of information we need will depend on the claims that need to be substantiated. If you’ve been issued with a formal Notice to Produce, you can submit documents containing clinical information that will be assessed by one of our medical advisers.

If we have asked you to participate in a Medicare compliance audit, we will ask you to provide documents that can substantiate claimed services.

Patient privacy

You’re not expected to produce clinical information about a patient unless it’s needed to substantiate a claim. You may censor any information that isn’t needed in all documents you provide.

You do not have to tell a patient that their clinical information has been disclosed for the purposes of a Medicare compliance audit, or as required or authorised by law.

The only time we notify a patient about the disclosure of their clinical information is when their clinical records are seized under a search warrant during a criminal investigation.

More information