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Medicare compliance audits

By now members will have received an information pack from the Department of Human Services about the requirements to produce documents to substantiate Medicare billing that came into effect in April 2011.

04 Sep 2011

By now members will have received an information pack from the Department of Human Services about the requirements to produce documents to substantiate Medicare billing that came into effect in April 2011.

Under the Health Insurance Act 1973 the Department of Human Services has the power to compel doctors to produce documents, including patient records if necessary, to substantiate Medicare billing. This power was part of a 2008-09 Federal Budget measure.

An exposure draft of the relevant legislation was the subject of a Senate inquiry in April 2009.  The AMA submission and evidence to that inquiry stressed the need to maintain the confidentiality of the doctor-patient relationship.  The AMA also had several meetings with the relevant Ministers during the development of the legislation.

As a result of AMA evidence to the Senate inquiry and persistent lobbying, the Act contains stronger safeguards for protecting patient privacy than it otherwise would have had.

The Act:

  • makes it clear that clinical information only has to be produced if there is no other information to substantiate a claim;
  • permits clinical information to be provided to a medical practitioner employed within the Department of Human Services in those situations; and
  • requires the Department to have regard to the types of documents, other than patient records, that could substantiate claims, and to consult with professional bodies such as the AMA on those matters.

The AMA supports reasonable audit strategies to maintain the integrity of the Medicare arrangements, but which protect patient privacy and the confidentiality of the doctor-patient relationship. The AMA has been providing input to the Department’s guidance on the types of documents that could substantiate a claim. For example, an extract of the appointment book or a receipt will be sufficient to substantiate that a patient attended for the service.

We are also working to improve the quality of information that the Department provides in letters sent to doctors who are the subject of an audit. For example, the letter should set out what the reasonable concern is that the Department has that the benefit may not have been payable.

If you are the subject of an audit and the only document you have to substantiate a claim is a patient record, then you can advise the audit officer that you wish to provide a relevant excerpt of the record to a medical practitioner employed within the Department. As the release of clinical information for this purpose is authorised by law, you do not need to inform your patients that their personal information may be disclosed to the Department in relation to services rendered to them.

The AMA continues to meet regularly with the Department to ensure its compliance strategies account for the complexities of the MBS and the realities of modern medical practice.


Published: 04 Sep 2011