Health professional guidelines

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

Page last updated: 23 December 2016

Health professional guideline groups

Health professional guidelines are presented in the following groups:

Formal notice to produce documents

Under section 129AAD of the Health Insurance Act 1973, if we have reasonable concern that you've been paid a benefit that exceeds the amount you should have been paid, we can ask you to substantiate your claims.

A formal notice to produce documents will be issued if you don't provide substantiating documents for Medicare compliance audit or review purposes.

Obligations under the 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’ll be asked to repay the money you received.

Voluntary acknowledgement

If you think you may have received an incorrect Medicare benefit or payment, you can voluntarily tell us. If you voluntarily acknowledge an incorrectly claimed benefit, you may be entitled to a reduced administrative penalty.
To do this you must complete the Voluntary acknowledgement of incorrect payments form.

Review of decision

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

You can do this by completing the Application to Review Compliance Audit Decision form.

You must apply to review a decision within 28 days of receiving notice that an amount is owing.

Record keeping

If you provide or initiate a service where a Medicare benefit is payable you should make sure you keep adequate and up to date records.
Records should:
  • clearly identify the name of the patient
  • have a separate entry each time the patient has attended a service
  • include the date the service was provided or initiated
  • contain enough information to explain the type of service provided
  • be clear enough so another practitioner, relying on the record, could effectively undertake the patient's ongoing care
  • be up to date, making sure it's completed at the time the service was provided or as soon as possible afterwards
  • be in either paper or electronic form
For more information about record keeping, go to the Administrative Record Keeping Guidelines or contact your relevant professional body.

Guidelines for substantiating claims for Medicare compliance purposes

If your require information on the types of substantiating documents required for specific services please refer to the relevant guideline.

Additional resources