Health Professional Compliance

This page includes information to assist health professionals comply with health payment requirements.

Page last updated: 28 September 2018

While the vast majority of Medicare providers do the right thing, the Department of Health has a role in ensuring that health professionals comply with the requirements of the Medicare Benefits Scheme (MBS) and other Medicare programs such as the Prescription Benefits Scheme (PBS) and incentive payment programs. This ensures that Medicare is serving the needs of Australian patients.

The Department has a strong program that protects Australia’s health payments system through the prevention, identification and treatment of incorrect claiming, inappropriate practice and fraud by health care providers and suppliers.

The Department continues to improve Medicare compliance arrangements by:

  • using data analytics to better target compliance activities
  • better targeting fraud, inappropriate practice and incorrect claiming investigations
  • assessing all tip-offs received as indicators of previously unknown compliance issues
  • using better debt recovery mechanisms and practices
  • using behavioural economics-driven approaches
  • making available education support resources for health professionals.

The Department will continue to consult with professional bodies and stakeholder groups on its compliance strategies and activities.

Overview

The Department’s compliance activities are focused on early intervention and prevention to help you:

  • get your correct entitlements
  • assist you to meet your obligations and responsibilities.

Compliance activities undertaken by the Department are targeted to the type of non-compliance identified, including:

  • professional review if inappropriate practice is identified
  • targeted letter campaigns where inadvertent non-compliance is identified
  • investigations are undertaken for suspected fraudulent activity and prosecution is considered where fraud is identified
  • audits where sustained or opportunistic non-compliance is identified.

The vast majority of health professionals and practice staff do the right thing and where non-compliance is identified it is often inadvertent. Because of this, we work with you to resolve any issues, especially if non-compliance is identified as a result of a genuine mistake. We also spend time focusing on early intervention and prevention, through support and education initiatives which aim to help you meet your obligations and responsibilities.

Where incorrectly claimed benefits have been identified, the Department will recover the money and you will need to repay any amounts incorrectly received, regardless of how the incorrect payment occurred.

Legislation

The legislation that makes us accountable for the payments we administer under Medicare is the Public Governance, Performance and Accountability Act 2013.

The Human Services (Medicare) Act 1973 sets out the functions and powers to administer Medicare. It also defines the programs that fall under the Medicare service delivery brand. The main health payment and services programs are:

MBS Legislation

  • Health Insurance Act 1973
  • Dental Benefits Act 2008
  • Veteran’s Entitlement Act 1986
  • Health and Other Services (compensation) Act 1995
  • Privacy Act 1988
  • Privacy Amendment (Enhancing Privacy Protection) Act 2012
  • Aged Care Act 1997
  • Private Health Insurance Act 2007

PBS Legislation

  • National Health Act 1953
  • Drug and Poisons Act and Regulations applicable in the States and Territories
  • National Health (Pharmaceutical Benefits) Regulations 2017

CDBS Legislation

  • Dental Benefits Act 2008

Changes to Legislation – Improved Medicare Compliance

The Health Legislation Amendment (Improved Medicare Compliance and Other Measures) Bill 2008 (the Bill) came into effect on 1 July 2018 and amends the:

  • Health Insurance Act 1973 (HIA)
  • Dental Benefits Act 2008 (DBA)
  • National Health Act 1953 (NHA).

The key changes are:

Summary of Legislation Changes for Health Professionals

GPs and Specialists (HIA) Allied health practitioners (HIA) Dentists (DBA) Pharmacists (NHA)
Record keeping Amended Records must be kept for a minimum of 2 years including referrals and documents created as a condition of claiming an MBS item. New Records must be kept for a minimum of 2 years including referrals and documents created as a condition of claiming an MBS item. Amended Records must be kept for a minimum of 2 years. New Records must be kept for a minimum of 2 years including prescriptions.
Provider Number Application form New The Department of Human Services Application for a Medicare Provider Number form has been changed to collect information about your employer. New The Department of Human Services Application for a Medicare Provider Number form has been changed to collect information about your employer. Not Applicable Not Applicable
Notice to produce documents to substantiate services No change No change No change New You are now required to produce copies of prescriptions when requested to do so by the Department to substantiate a PBS claim.
Allow debts to be raised for false or misleading statements No change No change No change New The Department can now recover benefits paid if you make a false or misleading statement (including administrative or unintentional errors).
Administrative penalties Amended Financial Administrative Penalties can be applied to a debt of more than $2,500 if you fail to provide substantiating documents within the required timeframe. Amended Financial Administrative Penalties can be applied to a debt of more than $2,500 if you fail to provide substantiating documents within the required timeframe. New Financial Administrative Penalties can be applied to a debt of more than $2,500 if you fail to provide substantiating documents within the required timeframe. New Financial Administrative Penalties can be applied to a debt of more than $2,500 if you fail to provide substantiating documents within the required timeframe.
Offsetting provisions New The Department can offset or deduct part or all of a debt from amounts payable to you after all rights of review have expired. New The Department can offset or deduct part or all of a debt from amounts payable to you after all rights of review have expired. No change Amended The Department can offset or deduct part or all of a debt from amounts payable to you after all rights of review have expired.
Garnishee provisions New The Department has the option to Garnishee debts from your bank account after all rights for review have expired. New The Department has the option to Garnishee debts from your bank account after all rights for review have expired. New The Department has the option to Garnishee debts from your bank account after all rights for review have expired. New The Department has the option to Garnishee debts from your bank account after all rights for review have expired.
Shared Debt Recovery Scheme New From 1 July 2019 the Shared Debt Recovery Scheme will allow the Department to hold an employing organisation responsible for a portion of debts incurred as a result of incorrect Medicare claiming. New From 1 July 2019 the Shared Debt Recovery Scheme will allow the Department to hold an employing organisation responsible for a portion of debts incurred as a result of incorrect Medicare claiming. Not Applicable Not Applicable

Guaranteeing Medicare - improving safety and quality through stronger compliance

In May 2018, the Government announced an investment of $9.5 million over five years from 2017-18 to continue to improve Medicare compliance arrangements and debt recovery practices to ensure Medicare services are targeted at serving the health needs of Australian patients. It was announced that in consultation with the Privacy Commissioner, legislation will be introduced to support improved compliance.

As part of the improved compliance measure, the Department of Health intends to review the arrangements relevant to section 135AA of the National Health Act 1953. Section 135AA of the National Health Act 1953 provides for the Australian Information Commissioner to make privacy rules that specify the requirements for storage and linkage of Medicare Benefits Schedule and Pharmaceutical Benefits Schedule information. The Department will continue to consult with key stakeholders on the improved compliance measures.

The Australian Government is committed to ensuring health information is stored securely and handled appropriately. Accordingly, the Department of Health intends to work with the Office of the Australian Information Commissioner in relation to the current privacy rules made under section 135AA, the Privacy Guidelines for the Medicare Benefits and Pharmaceutical Benefits Programs and more broadly, the review of arrangements relevant to section 135AA of the National Health Act 1953. For more information, or to view the privacy rules, please visit the OAIC’s website.

Feedback

To provide feedback on health compliance, email combined.compliance@health.gov.au.