Compliance strategy
Our Health Provider Compliance Strategy 2025–30 outlines how we use a risk and proportion-based approach to compliance. We aim to:
- prevent incorrect claiming
- support providers to get it right
- effectively address non-compliance when it occurs, contributing to a sustainable Medicare system.
Compliance priorities
Our published 2025 compliance priorities reflect our commitment to act. We also monitor and plan for environmental changes. This means our compliance priorities may evolve in response to emerging risks. Read more about our current activities.
Finding non-compliance
We monitor claiming data, collect information and carry out targeted data analysis to find non-compliance. We consider:
- information and data alongside policy and clinical advice
- the context of the broader environment
- stakeholder advice to better understand compliance concerns.
We continue to improve our advanced analytical modelling to detect fraudulent claiming. We also use data matching to find potential non-compliance.
Tell us if you have a concern about billing, prescribing or claiming, or suspect fraud of a healthcare practitioner, their practice or their employee.
Responding to non-compliance
Based on our assessment of a compliance concern, we may pursue a range of options. This may include:
- prevention and education
- enforcement
- peer review
- investigation into breaches of Australian laws.
We decide our compliance response considering available information. We also prioritise resources and effort based on the seriousness and scale of the identified concern.
Prevention
Our preferred method of achieving compliance is through prevention and education. We aim to introduce controls that stop health practitioners from getting it wrong.
We evaluate our compliance activities and apply learnings to future activities. This also informs the design of health policy.
Education and support
We provide educational resources and personal support to help you meet your legal obligations as a health practitioner and reduce the risk of incorrect billing under Medicare.
This includes:
- Understanding Medicare: Provider Handbook, which provides comprehensive guidance for healthcare professionals and others on navigating the Medicare system
- AskMBS advisories, which provide advice on common issues
- AskMBS email advice service, which advises on how to interpret and apply MBS items, explanatory notes, and associated legislation, with no involvement in MBS compliance
- targeted letters to promote early intervention
- using our knowledge of behaviour to improve compliance.
Find out how to comply.
Targeted letters
We send targeted letters to educate and alert you when your claiming patterns show you are at risk of non-compliance. Targeted letters help you:
- review your claims
- find and correct any errors by making a voluntary acknowledgement
- understand how to claim correctly in the future
- repay any accrued debt.
Responding to a targeted letter is voluntary, but it is in your best interest to do so. When we monitor future claiming and decide whether to undertake an audit or other intervention, we will consider any:
- information you provided to explain your claiming
- corrections you made to claims
- changes in your claiming patterns following our letter.
Behavioural insights and interventions
We use our knowledge of behaviour to improve compliance through:
- finding behaviours of concern and what might influence that behaviour, then removing the barriers to its change
- developing interventions based on research and behavioural science
- using robust evaluation, such as randomised controlled trials, to decide whether interventions are working.
For example, to help combat antimicrobial resistance, we trialled sending general practitioners who prescribed a lot of antibiotics a comparison of their data and that of their peers. This resulted in a significant reduction of antibiotic prescriptions.
Read the Nudge vs Superbugs 6-month report and 12-month follow-up report.
Enforcement
We conduct compliance audits and reviews for the MBS, PBS, CDBS and incentive programs. We may need to collect information from you for these activities.
If we have reasonable concerns about your Medicare claiming, we may issue a notice asking you to produce relevant documents to substantiate your Medicare claims. We will raise a debt for the service if:
- you don't provide the documents we asked for
- the documents do not prove your professional service or claims were legitimate.
You may also face civil penalties if you have the records requested in the notice and don’t produce them.
If you’re being audited, read our fact sheets for the:
If we make a decision that amounts are recoverable following a compliance activity that you don't agree with, you can ask for a formal review.
You can ask for a review of decision if:
- an amount of money can be recovered from the decision
- we have not already reviewed the decision at your request.
When applying:
- apply within 28 days of getting our ‘notice of decision to claim a debt’ letter
- use the approved application form
- make sure the application form is accurate and complete
- attach relevant additional information so that the review officer has everything they need.
If you are unsatisfied with the review officer’s decision, you may seek further review through the Administrative Review Tribunal or other appropriate jurisdiction. You cannot ask for a review of decision if the person or estate has waived the right to review in writing.
Peer review
The Practitioner Review Program identifies potential inappropriate practice by health practitioners who bill, claim or prescribe under the MBS, CDBS and PBS.
If we believe the 80/20 or 30/20 rule may have been breached, or after we finalise a review, and we we still can’t be sure that inappropriate practice has not occurred, we refer cases to the Professional Services Review (PSR) for an independent professional review.
The PSR’s peer review processes ensure that appropriately qualified people decide whether your conduct would be unacceptable to most members of your profession or specialty.
Fraud investigations
We investigate suspected Medicare fraud from health practitioners, such as claiming for medication or services that were not provided. Our investigations follow the:
We will offer you the opportunity to attend an interview to explain your practice.
If necessary, we can use powers under the national Human Services (Medicare) Act 1973 to require you to provide information or conduct search warrants.
We sometimes work with the police, and might refer matters to the Commonwealth Director of Public Prosecutions for possible criminal prosecution.