The Health Insurance Amendment (Compliance) Act 2011 amends the Health Insurance Act 1973 and introduces new laws that relate to services rendered on or after 9 April 2011. There are now changes to obligations and procedures for Medicare compliance audits for incorrect payments and unsubstantiated services. To help you understand these changes, the following resources have been developed:
The fact sheet provides information about the changes to the Health Insurance Act 1973, including details on the new compliance audit notices you may receive, the opportunity for you to request a review of a decision and administrative penalties that can apply.
- Increased Medicare Compliance Audit (IMCA) Fact sheet [PDF, 205Kb]
- Increased Medicare Compliance Audit (IMCA) Fact sheet [RTF, 65Kb]
The flow chart provides a graphical overview of a Medicare compliance audit reflecting changes to the legislation.
The FAQs answers questions you may have about the changes to the legislation and how you may be affected by a Medicare compliance audit.
Should you become aware of any incorrect payments you may have received under the Medicare program, you can now voluntarily tell the Department of Human Services. To do this you must fill out the approved Voluntary acknowledgement of incorrect payments form. This form can be used at any stage you become aware of receiving an incorrect payment.
Note: when you are voluntarily acknowledging incorrect payments, clinical notes or money should not be sent with the form. We will contact you to confirm the amount owing.
Where you become aware of incorrect payments you may have received under other programs, private health insurers or concerning payment for a patient who received cover or medical treatment under a compensation scheme after the consultation occurred, refer to the information below:
- Department of Veterans' Affairs claims contact the Department of Human Services Veterans' Affairs Processing enquiry line on 1300 550 017 and select Option 1
- the private health insurer directly
- if the incorrect payment relates to a patient who received cover or medical treatment under a compensation scheme after the consultation occurred, contact the Medicare Provider enquiry line 132 150 and select Option 1.
Under the changes to the Health Insurance Act 1973, penalties may now apply to incorrect payments or unsubstantiated services. There is a penalties FAQ sheet to help you understand the administrative and civil penalties that may apply.
Note: Penalties do not apply to debts that became due more than two years prior to an audit or to services claimed before 9 April 2011.
If we have asked you to participate in a Medicare compliance audit, we will ask you to provide documents that can substantiate your claimed services. When handling sensitive information we are bound by legislation and have high standards of privacy protection so that the information we collect is protected.
We have developed a FAQ sheet to explain our Privacy standards and help you understand your obligations.
We can now issue a formal notice to a health professional or a person in charge of their documents, requiring them to produce documents to substantiate services claimed under the Medicare program. More information is available in the Notice to Produce Documents fact sheet.
The new laws give you the opportunity to seek a review of a decision if you do not agree with a decision to recover amounts. The request for a review of decision must be received within 28 days of receipt of a notice of decision.
To request a review of decision you must complete the approved Review of Decision form.
If you have feedback in relation to a Medicare compliance audit finding then please email email@example.com
Alternatively you can mail your feedback to:
Department of Human Services
PO Box 1001
Tuggeranong ACT 2901
The Exceptional Circumstances FAQ sheet provides information about circumstances beyond a person’s control that affect your ability to participate in a Medicare compliance audit. Should you be facing circumstances beyond your control, it is recommended that you tell the department as soon as you can. To do this you must fill in the Compliance Audit – Exceptional Circumstances Statutory Declaration form.
If you need more information about the changes to legislation please email firstname.lastname@example.org
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Last updated: 9 April, 2013