Health professional guidelines

Health professional guidelines

Health professional guidelines help you understand what documents you can use to substantiate services if you are asked to participate in a Medicare compliance audit or review.

• Health professional guidelines
• Formal notice to produce documents
• Obligations under the Public Governance, Performance and Accountability Act 2013
• Voluntary acknowledgement
• Review of decision
• Record keeping
• Additional Resources

Health professional guidelines

• Guideline for substantiating dental services provided under the Child Dental Benefits Schedule (CDBS)
• Guideline for substantiating valid individual Allied Health Services were provided (for allied health professionals)
• Guideline for substantiating that a valid Allied Mental Health service has been provided (for allied health professionals)
• Guideline for substantiating claims for diagnostic imaging and pathology services rendered to emergency department patients of public hospitals
• Guideline for substantiating personal performance by a consultant physician/specialist in public hospital
• Guideline for substantiating services provided under rights of private practice at public hospital outpatients departments
• Guideline for substantiating Ears, Nose and Throat Surgical Services
• Guideline for substantiating proof of malignancy
• Guideline for substantiating optometry services
• Guideline for substantiating that a patient attended a service
• Guideline for substantiating that a specific treatment was performed
• Guideline for substantiating that a valid referral existed (from specialist or consultant physician)
• Guideline for substantiating that a valid referral existed (from pathology or diagnostic imaging)
• Guideline for substantiating that a patient had a pre-existing condition at the time of the service
• Guideline for substantiating Medicare Benefits Schedule requirements for a patient with Type 2 Diabetes
• Guideline for substantiating preparation of a valid GP Management Plan (for medical practitioners)
• Guideline for substantiating coordination of the development of Team Care Arrangements (for a medical practitioner)
• Guideline for substantiating preparation of a valid GP Mental Health Plan (for a medical practitioner)
• Guideline for substantiating urgent attendance after hours services

Record keeping

If you provide, or initiate, a service where a medical or pharmaceutical benefit is payable it is important that you keep adequate and up to date records. All health professionals are required to keep and maintain records for a minimum period of two years.

Records should:

• clearly identify the name of the patient
• have a separate entry for each patient attendance or service
• include the date the service was initiated or provided
• contain enough information to explain the type of service provided
• be clear enough so another health professional, relying on the record, could effectively undertake the patient's care
• be up to date by creating the record during or as soon after the treatment or service occurred
• be either in a paper or electronic form.

For more information about record keeping, go to the Administrative Record Keeping Guidelines or contact your relevant professional body.

Formal notice to produce documents

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

A formal notice to produce documents can be issued if you don't voluntarily provide substantiating documents when you are asked to participate in health payment compliance activities.

Obligations under the Public Governance, Performance and Accountability Act 2013

Under the Public Governance, Performance and Accountability Act 2013, we must recover money owed to the Australian Government. If you incorrectly claim a Medicare benefit or receive an incorrect payment, you will be asked to repay the money you received.

Visit Paying your Medicare compliance debt for more information.

Voluntary acknowledgement

If you think you have received an incorrect benefit or payment, it is important you let us know as soon as possible. Tell us about an incorrectly claimed or paid benefit by completing a Voluntary acknowledgement of incorrect payments form.

Review of decision

In some circumstances you can apply to have the decision of a Medicare compliance audit reviewed if you are advised to repay an incorrectly paid or claimed benefit.

You can apply for a review of decision within 28 days of receiving a notice that an amount is owing by completing the Application to Review Compliance Audit Decision form.

Additional Information

• Health provider compliance audits and reviews
• Medicare forms for health professionals
• MBS Online
• Health Insurance Act 1973
• Federal Register of Legislation