About Medicare compliance

Our compliance program helps to ensure all Medicare claims are correct and legitimate. This helps keep our healthcare system sustainable and ensures we remain accountable to Australian taxpayers for payments we make under Medicare.

What Medicare compliance is

Health practitioners and organisations must meet legislative requirements when they receive incentive payments, bill or claim for subsidised services or dispense or prescribe subsidised medicines under the:

Medicare compliance is about ensuring health practitioners correctly follow these requirements, in line with relevant laws.

Read about when Medicare compliance applies.

Why Medicare compliance is important

Compliance with legislative Medicare requirements helps to:

  • maintain the high quality and integrity of Australia’s healthcare system
  • ensure Medicare remains sustainable by paying only legitimate claims.

It benefits patients by ensuring:

  • health care is clinically relevant and appropriate
  • health records for future treatments remain appropriate
  • the correct number of health services that have limited uses each year.

Compliance also benefits health practitioners and practices by preventing the potentially major costs and impacts of non-compliance.

Costs and impacts of non-compliance

For health practitioners and practices, non-compliance can result in:

  • fines and debts you’ll need to repay 
  • reputation damage
  • higher insurance premiums that might result from compliance issues
  • potential court action in the case of fraud
  • administrative burden from having to resubmit claims, submit a voluntary acknowledgement for incorrect claims, or substantiate claims following a notice to produce documents.

Read more about Medicare non-compliance debts and penalties.

Who is involved in Medicare compliance

We are responsible for activities to help health practitioners meet their legal obligations and detect fraud including:

Where inappropriate practice by a practitioner or a corporate is suspected, we refer cases to the Professional Services Review scheme.

Read more about our compliance activities.

Stakeholders we work with to promote compliance include:

  • the Department of Veterans’ Affairs – manages healthcare payments for veterans
  • Services Australia – manages payments made under Medicare and its programs, and does compliance audits and reviews for the MBS, PBS, CDBS or PIP.
  • peak professional bodies – provide support and information to their members
  • indemnity insurers – support health practitioners undergoing audits.

How to report suspected Medicare non-compliance 

If you are concerned about the billing or claiming, or suspect fraud of a healthcare practitioner, their practice or their employee, notify us.

Find out more about reporting incorrect billing, claiming or suspected fraud.

Date last updated:

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