Health Professional Compliance

Page last updated: 24 November 2017

Overview
Legislation
Medicare Benefits Schedule (MBS)
Pharmaceutical Benefits Scheme (PBS)
Child Dental Benefits Schedule (CDBS)
Proposed amendments to Legislation
Reviews and Reports
Resources
Feedback

Overview

Compliance activities are focused on early intervention and prevention to help you get your correct entitlements, and assist you to meet your obligations and responsibilities. These activities target areas of inappropriate practice and fraudulent activity. Prosecution is considered where fraud is identified. We work with you to resolve any issues, if you have not complied with reporting requirements because of genuine mistakes.

Where we identify incorrectly claimed benefits, we will recover the money and you will have to repay amounts incorrectly received, regardless of how the incorrect payment occurred.

We work very closely with a wide range of stakeholders to ensure they are well informed on all aspects of our compliance approach.

We undertake education and compliance strategies to meet legislative requirements. The Human Services (Medicare) Act 1973 sets out the functions and powers to administer Medicare. It also defines the programs that fall under the Medicare service delivery brand.

Legislation

The legislation that governs the main health payment and services programs are the Medicare Benefits Schedule (MBS), the Pharmaceutical Benefits Scheme (PBS) and the Child Dental Benefits Schedule.

MBS

  • Health Insurance Act 1973
  • Dental Benefits Act 2008
  • Public Governance, Performance and Accountability Act 2013
  • Veteran’s Entitlement Act 1986
  • Health and Other Services (compensation) Act 1995
  • Privacy Act 1988
  • Privacy Amendment (Enhancing Privacy Protection) Act 2012
  • Aged Care Act 1997
  • Private Health Insurance Act 2007

PBS

  • National Health Act 1953
  • Drug and Poisons Act and Regulations applicable in the States and Territories
  • National Health (Pharmaceutical Benefits) Regulations 2017
The legislation that makes us accountable for the payments we administer under Medicare is the Public Governance, Performance and Accountability Act 2013.

CDBS

  • Dental Benefits Legislation Amendment Act 2014

Proposed amendments to Legislation

The government is proposing to make amendments to the legislation that governs the compliance activities used to protect Medicare, the Pharmaceutical Benefits Scheme and dental payments. The proposed amendments involve the Health Insurance Act 1973, the National Health Act 1953 and the Dental Benefits Act 2008.

Gaining the views from stakeholders on these amendments is important.

Your organisation can provide a written submission on the consultation paper through the Department’s consultation hub:

The online submission process will open on Friday 15 September 2017 at 9:30am and close on Sunday 8 October 2017 at 11:59pm.

Reviews and Reports

Fraud prevention and compliance – Increased billing assurance for the Medicare Benefits Schedule

The 2012-13 Budget measure, ‘Fraud prevention and compliance – Increased billing assurance for the Medicare Benefits Schedule’ (the Large Practices Project), was implemented over a three-year period from 1 July 2012 to 30 June 2015. The Budget measure was proposed in recognition of the Medicare compliance challenges associated with the changing nature of health practice, from small owner-operated medical practices to larger business enterprises. The objectives of the project were to understand and address compliance challenges for large health practices in billing accurately under Medicare.

The complete report can be downloaded by following the links below:
Fraud prevention and compliance – Increased billing assurance for the Medicare Benefits Schedule (PDF 6400 KB)
Fraud prevention and compliance – Increased billing assurance for the Medicare Benefits Schedule (Word 5427 KB)

Fraud prevention and compliance – Improve billing practices within public hospitals’ Budget measure

The ‘Fraud prevention and compliance – Improve billing practices within public hospitals’ Budget measure (known as the Inappropriate Billing Project ) was implemented over a four year period from 1 July 2012 to 30 June 2016. The aim of the project was to review, understand and address inappropriate billing of Medicare by hospital emergency department patients for pathology and diagnostic imaging services. In late 2014, the scope of the project was expanded to include education and compliance interventions for a broader range of topics related to claims to Medicare in public hospitals. There was also a need to explore whether legislative amendments may be required to resolve operational issues with undertaking compliance interventions in the public hospital sector.

The complete reports can be downloaded by following the links below:
Fraud prevention and compliance – Improve billing practices within public hospitals’ Budget measure (PDF 1432 KB)
Fraud prevention and compliance – Improve billing practices within public hospitals’ Budget measure (Word 1215 KB)

Resources

Feedback

To provide feedback on health compliance, email Combined Compliance.