Our Medicare compliance activities

We are accountable for payments made under Medicare programs. We review and audit health practitioners’ claims to make sure they are legitimate. We support health practitioners to comply with Medicare requirements, with a focus on prevention and early intervention.

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:

Our educational resources can earn you continuing professional development points.

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.

Data matching

We do routine data matching of health practitioners’ MBS and PBS claiming data to find possible incorrect billing, inappropriate practice and fraud.

When working with practitioners’ data, we:

  • transfer it securely
  • match it in secure environments
  • apply strict security controls
  • only allow authorised staff to access it when required for their duties.

If data matching identifies potential wrongdoing, our compliance officers carry out audits or investigations through prescribed and legislated compliance processes.

Data matching does not:

  • expand our compliance powers
  • change how we do compliance activities
  • impose any changes or new obligations on health providers
  • authorise the automation of compliance outcomes or the raising of debts.

The following legislation and regulations dictate how we can data match:

We also publish a privacy impact assessment of our data matching activities.

Our data matching activities comply with the:

Targeted letter campaigns

We send targeted letters to alert you when your claiming patterns show you are at risk of non-compliance. 

Many instances of incorrect payments are accidental. Targeted letters help you:

Responding to a targeted letter is voluntary, but it is in your best interest to do so. When monitoring future claiming and deciding 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.

Audits

We conduct compliance audits and reviews for the MBS, PBS, CDBS and incentive programs.

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:

Review of decision

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 Appeals 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.

Practitioner Review Program reviews

The Practitioner Review Program identifies potential inappropriate practice by health practitioners who bill, claim, dispense or prescribe under the MBS, CDBS and PBS.

Through routine monitoring of Medicare billing and prescribing, we identify health practitioners whose patterns: 

  • vary significantly from  those of their peers, which might indicate inappropriate practice
  • show a large number of daily services, which might indicate a prescribed pattern of services.  

Case referral to the Professional Services Review

If, after we finalise a review, we believe the 80/20 or 30/20 rule may have been breached, or 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.

Learn more

Health Provider Compliance Strategy 2021–22

The Health Provider Compliance Strategy aims to help health providers understand their responsibilities in relation to compliance. It outlines the Department's compliance priorities for the 2021-22 financial year and describes the tools and methods used to identify and treat non-compliance.
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