Medicare compliance laws
The compliance requirements of Medicare programs are set in legislation. The requirements apply to us and to health professionals.
The Public Governance, Performance and Accountability Act 2013 holds Health accountable for payments we make under Medicare. We must recover money owed to the Australian Government, such as incorrect claims for Medicare benefits.
Child Dental Benefits Schedule (CDBS)
The CDBS provides funding for basic dental services to eligible children. The CDBS covers services provided in public and private settings. It does not cover orthodontic or cosmetic dental work, or any services provided in a hospital.
Compliance obligations are set by the Dental Benefits Act 2008.
Human Services (Medicare) Act 1973
The Human Services (Medicare) Act 1973 sets out the functions and powers for the administration of Medicare. This includes the payment of benefits and the investigation of fraudulent claiming.
The Act provides us particular powers during a fraud investigation. It allows us to:
- issue a notice requiring a person to give information or produce documents (see notice to produce)
- enter premises with the consent of the occupier and conduct a search for monitoring compliance with regulatory requirements
- enter premises, conduct searches and seize material under warrant, where there are reasonable grounds for believing that a relevant offence is being or has been committed. This will occur if the Chief Executive of Medicare has approved the use of the Act’s authority for that specific investigation.
Medicare Benefits Schedule (MBS)
The MBS lists the services covered by Medicare, including consultations, diagnostic tests and operations. MBS compliance obligations are set by the Health Insurance Act 1973 and associated regulations.
National Health Reform Agreement
The National Health Reform Agreement (NHRA) sets out the shared intention of the Australian Government and the state and territory governments. It works in partnership to improve health results for all Australians. It also seeks to ensure the sustainability of the Australian health system.
The NHRA includes financial and governance arrangements for:
- public hospital services
- primary health care
- aged care.
Practice Incentive Program (PIP)
PIP encourages general practices to continue providing quality care, enhance capacity, and improve access and health outcomes for patients. Services Australia administer PIP on our behalf. PIP has 9 individual incentives under 3 payment streams.
Pharmaceutical Benefits Scheme (PBS)
The PBS lists the prescription medicines which are subsidised under Medicare for PBS approved suppliers.
Compliance obligations are set by the:
- National Health Act 1953
- Drug and Poisons Act and Regulations applicable in the states and territories
- National Health (Pharmaceutical Benefits) Regulations 2017
- National Health (Listing of Pharmaceutical Benefits) Instrument 2012 (PB 71 of 2012).