The Health Benefit Compliance program aims to support the integrity of Australia’s publicly subsidised health funding schemes by identifying and treating incorrect claiming, inappropriate practice and fraud by health providers. Where applicable, this can include the recovery of funds which have been incorrectly claimed. Given the large volume and value of health care providers’ claims, it is important to assess whether the Department of Health has an effective approach to the prevention, identification and treatment of incorrect claiming, inappropriate practice and fraud by health care providers and suppliers.
The audit objective was to assess the effectiveness of the Department of Health’s approach to health provider compliance.
To form a conclusion against the audit objective, the following high-level criteria were adopted:
- approaches to identify, prioritise and treat non-compliance are appropriate; and
- oversight arrangements for monitoring health provider compliance outcomes are appropriate and inform future compliance approaches.
The audit did not examine Health’s passive compliance activities, such as education, or debt recovery processes.
- The Department of Health’s approach to health provider compliance was partially effective.
- In the period examined, the Department's approaches to identifying, prioritising and treating non-compliance were partially appropriate. The absence of a risk-based approach in identifying and prioritising which compliance projects were selected for operational activity limited the effectiveness of the approach. Health advised that it is in the process of implementing a revised compliance model that includes risk-based processes and structures.