Compliance and fraud investigation

Compliance

We are focussed on early intervention and prevention to help customers get their correct entitlements, and assist you to meet your obligations and responsibilities. We also work with you to resolve any issues made because of genuine mistakes. Where there is deliberate fraud, the matter may be referred for a criminal investigation. Where incorrectly claimed benefits are identified, we work to recover the money.

Protecting taxpayer dollars

We are responsible for protecting the integrity of the health programmes we administer by ensuring only eligible services are paid for. To protect taxpayer dollars, we are committed to ensuring that the right person, doctor, specialist, pharmacist or patient, receives the right payment at the right time.

Compliance risk analysis and treatment 

We conduct compliance audits with you to verify details of services when there is a concern that payments are incorrect. If we find claiming that appears incorrect, you are given the opportunity to respond. If an audit also identifies behaviour that may be fraudulent, a criminal investigation may result.

We continually assess and monitor the compliance risks for health programmes using the best available evidence, including information from data analysis, reviews and audits.

To understand emerging risks we keep up to date with the latest developments and trends and we consult with a wide range of stakeholders, such as the Australian Medical Association, Royal College of General Practitioners and the Pharmacy Guild of Australia, to gain a better understanding of factors that affect compliance. We analyse data including health provider claiming patterns, information received through tip offs and information from environmental scanning to determine which compliance activities to undertake. Educational activities, audits, investigations and the Practitioner Review Program verify, assess and test compliance to ensure that benefits are claimed correctly.

Fraud investigation

What you need to know

Fraud against the Commonwealth is defined as ‘dishonestly obtaining a benefit, or causing a loss, by deception or other means’. We have investigators in each state who investigate fraud by health professionals and the general public against the Medicare programme, the Pharmaceutical Benefits Scheme and other government programmes we administer. In some cases, investigations are conducted in liaison with state and Federal Police.

If you or a member of the public is engaging in criminal or fraudulent activity, your case may be referred to the Commonwealth Director of Public Prosecution for consideration for potential criminal prosecution.

TheHuman Services (Medicare) Act 1973 provides us with additional authority to perform functions in relation to fraud investigation.

The act allows us to:

  • issue a notice requiring a person to give information or produce documents
  • enter premises with the consent of the occupier and conduct a search for the purpose of monitoring compliance with regulatory requirements
  • enter premises, conduct searches and seize material under warrant, where there are reasonable grounds for believing that a relevant offence is being or has been committed, and the Chief Executive Medicare has approved the use of the Acts authority for that specific investigation

Under section 42(1) of the Human Services (Medicare) Act 1973 we are required to report the use of this additional authority in our Annual Report.

Reporting suspected fraud

To report suspected fraud call 131 524 or fill out the Reporting suspected Fraud (1980) form.