We audit healthcare providers to ensure that all Medicare benefits paid to them comply with the requirements needed to receive them. We do this under the National Health Act 1953, Health Insurance Act 1973 and the Dental Benefits Act 2008.
We conduct compliance audits and reviews for:
- the Medicare Benefits Schedule (MBS)
- the Pharmaceutical Benefits Scheme (PBS)
- the Child Dental Benefits Schedule (CDBS)
- Incentives Programs.
Notice to produce
Sometimes, we issue a ‘notice to produce’ to health care practitioners or corporations. In this notice, we ask for access to documents because a reasonable concern has come up in relation to claiming or payment of a Medicare benefit.
We may raise a debt for the service. We will only do so if you don't provide the documents, we asked for. Or, if the documents do not prove your professional service or claims.
If a person has control of a health provider’s records and does not produce the documents requested in the notice, they may face civil penalties.
Review of decision
One of our independent decision makers decides when to claim a debt from a compliance audit. Our review officers may confirm, vary or revoke the original decision.
To ask for a review of decision you must complete an Application to Review Compliance Audit Decision form.
You can ask for a review of decision under any program including MBS, PBS and CDBS. However, the following conditions apply:
- there must be an amount of money recoverable from the decision
- we have not already reviewed the decision at your request
- we have received the application for review within 28 days of sending you the 'notice of decision to claim a debt' letter.
If you are unsatisfied with the decision reached by the review officer, you may seek further review through the AAT or other appropriate jurisdiction.
You cannot ask for a review of decision if the person or estate has waived the right to review of the decision in writing.
Making an application for review
When submitting your application for review, you can provide additional information that substantiates the benefit paid for a service. This will ensure our review officer has all the relevant information to start the review for you.
When applying for a review of a decision make sure:
- you use the approved application form provided on our website
- the application form is accurate and complete
- you attach any additional information when you submit the application
- you submit the application in 28 days of getting the receipt from the ‘notice of decision to claim a debt’ letter.
Review of decision
Primary contact for a request for a review of decision of a compliance audit.