Health provider compliance audits and reviews

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Page last updated: 23 December 2016

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Keeping records

You should keep adequate and contemporaneous records (see Administrative record keeping guidelines for health professionals).

In the case of Child Dental Benefit Schedule (CDBS), dental practitioners are required to keep clinical records, including informed financial consent from the patient or their parent or legal guardian for 4 years.

The clinical records must also document the tooth or teeth that were treated when an item number relates to a particular tooth or teeth. 

For more information about CDBS, read the Dental Benefit Rules 2014 on the Federal Register of Legislation website.

In cases other than CDBS we may require you to provide documents substantiating services for up to 2 years under the legislation. However, your relevant professional peak body may also provide guidance about record keeping that is appropriate for your practice.

Providing clinical records

You only need to provide documents with the clinical details of a patient to us where this is necessary to substantiate a service. You can provide an excerpt with only the relevant details to a compliance officer or you can choose to provide any documents with clinical information to a Department of Health medical adviser.

We can issue a notice to any person in possession or control of your documents. If this person does not comply with a request, they can be subject to a civil penalty. We cannot issue a notice to a patient or their parent or legal guardian.

Health provider compliance audits and reviews

Health provider compliance audits and reviews are conducted in accordance with legislation, to protect public funds and make sure benefits are correctly paid.

Once a Medical Benefit Schedule (MBS) compliance audit has started, you will still have the opportunity to tell us that an incorrect amount has been paid. The administrative penalty maybe reduced depending upon when you tell us about the incorrect payment.

If a MBS compliance audit has started but you have not yet received a formal Notice to Produce substantiating documents and you voluntarily tell us you received an incorrect payment, the administrative penalty will be reduced to 10%.

If you have received a formal Notice to Produce substantiating documents relating to MBS items, you can voluntarily tell us about an incorrect payment to reduce the administrative penalty to 15%. This must be done before the timeframe to respond expires.

In the case of a CDBS compliance audit, you can voluntarily tell us about an incorrect payment at any time, however administrative penalties do not apply to CDBS compliance audits.

Notice to Produce

A Notice to Produce is a written notice requiring a health or dental practitioner, or person in possession or control of records, to produce documents that can substantiate the services being looked at as part of a MBS or CDBS compliance audit.

Read more about a notice to produce

Administrative penalties

Under the Health Insurance Act 1973, penalties now apply to incorrect payments or unsubstantiated services for which a MBS benefit has been paid.

Read more about administrative penalties

Voluntary acknowledgement of incorrect payments

We conduct health provider compliance audits and reviews in accordance with our Compliance Program and legislation in order to protect public funds and ensure benefits are correctly paid.

Read more about voluntary acknowledgement of incorrect payments

Compliance audit outcome

You will be advised in writing of the outcome of the compliance audit before a debt is raised.

If you disagree with the outcome of a compliance audit you can lodge an Application to Review Compliance Audit Decision form. You will need to submit your application within 28 days of receiving the notice of decision that amounts are recoverable and provide any additional information and substantiating documents. We will respond to your application within 28 days after receiving your application.

Exceptional circumstances

The following information is about circumstances beyond a person’s control that affect your ability to participate in a health compliance audit. Should you be facing circumstances beyond your control, we recommend that you tell us as soon as you can.

Health provider compliance audits and reviews are conducted in accordance with legislation, to protect public funds and make sure that benefits are correctly paid.

An exceptional circumstance is an unavoidable situation that stops you substantiating services provided or fulfilling requests we make to produce documents, even after you have taken all possible and reasonable precautions.

If you think you have exceptional circumstances, you should tell us as soon as you can.

If an audit is in progress and we are not satisfied with the reasons set out in your submissions, you will still need to either:
    • substantiate any services subject to the audit
    • repay any incorrect payments including any penalties that may apply
If we are satisfied, we will send you a Notice of Decision.

Fill out a Compliance Audit - Exceptional Circumstances - Statutory Declaration form so we can assess your situation. This form provides you with information on how to submit your form and where you can get further help.

Mail the form to the Exceptional Circumstances team.

Civil penalties

A civil penalty is similar to a fine and can be imposed by the Federal Court on an individual or a corporation who:
    • is responsible for documents relating to claimed MBS or CDBS services
    • did not provide the service themselves, and
    • has not complied with a Notice to Produce documents
Penalties are designed to encourage voluntary compliance with the legislative requirements for the payment of benefits.

A civil penalty does not apply to patients who received MBS or CDBS services or incurred the expenses associated with a MBS or CDBS service.

Civil penalty rates

The Federal Court can impose a civil penalty of an amount described under 4AA in the Crimes Act 1914, for each service listed in a formal notice where a third party has not provided the required documentation relevant to that service.
 

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