Commonwealth Consolidated Acts Commonwealth Consolidated ActsWhen section applies
(1) This section applies if the Chief Executive Medicare (the CEO ):
(a) has a reasonable concern that an amount paid, purportedly by way of benefit or payment under this Act, in respect of one or more professional services, may exceed the amount (if any) that should have been paid; and
(b) has taken into account advice given to him or her by a medical practitioner who is a Departmental employee (within the meaning of the Human Services (Medicare) Act 1973 ) about the types of documents that contain information relevant to ascertaining whether amounts paid in respect of professional services of the same kind or kinds as the service or services referred to in paragraph (a) should have been paid.
Note: For the purposes of paragraph (a), the CEO may, for example, have a reasonable concern about benefits or payments made in respect of:
(a) professional services rendered by individual practitioners; or
(b) professional services rendered by particular kinds of practitioners; or
(c) the rendering of services to which specific items, or groups of items, relate.
CEO may require person to produce document etc.
(2) If the CEO believes on reasonable grounds that:
(a) a person:
(i) who rendered a professional service in respect of which an amount has been paid that is the subject of the CEO's concern; or
(ii) on whose behalf such a professional service was rendered; or
(b) subject to subsection (7), another person;
has possession, custody or control of one or more documents relevant to ascertaining whether the amount paid in respect of the professional service should have been paid, or whether a determination under subsection 129ACA(2) should be made, the CEO may, by written notice given to the person, require the person to do any or all of the things mentioned in subsection (5) of this section.
(3) The CEO may give a notice to a person under subsection (2) in respect of a professional service only if the CEO has given the person a reasonable opportunity to respond to a written request to produce to the CEO, or a Departmental employee (within the meaning of the Human Services (Medicare) Act 1973 ), documents relevant to either or both of the following:
(a) ascertaining whether the amount paid, purportedly by way of benefit or payment under this Act, in respect of the service, should have been paid;
(b) whether the CEO should make a determination under subsection 129ACA(2) in relation to the amount paid, purportedly by way of benefit or payment under this Act, in respect of the service.
(4) A notice may only be given in respect of a professional service for which a claim for an amount to be paid under this Act in respect of the service was made during the period mentioned in subsection (4A).
(4A) The period is 2 years immediately before the day a written request under subsection (3) was first given to the person in relation to one or more professional services specified in the notice.
(5) The CEO may require the person, in relation to each professional service specified in the notice:
(a) subject to subsection (6), to produce to the CEO, or a Departmental employee (within the meaning of the Human Services (Medicare) Act 1973 ), any document, or extract of any document, that is relevant for a purpose set out in subsection (2); or
(b) to make a copy of any such document or extract and to produce that copy to the CEO or employee.
Note: For a person referred to in paragraph (2)(a), failure to comply with a notice may lead to recovery action (see sections 129AC and 129ACA) and an administrative penalty may be applied (see sections 129AEA, 129AEB and 129AEC). For a person referred to in paragraph (2)(b), failure to comply with a notice may lead to a civil penalty (see section 129AAE).
(6) If a document, extract or copy contains clinical details relating to an individual, the person to whom the notice is given is not required to produce the document, extract or copy to a person other than a Departmental employee (within the meaning of the Human Services (Medicare) Act 1973 ) who is a medical practitioner.
CEO not to give notice to certain persons
(7) A person referred to in paragraph (2)(b) does not include:
(a) the person in respect of whom the professional service was rendered; or
(b) the person who incurred the medical expenses in respect of the service.
Content of notice
(8) The notice must:
(a) specify details of each professional service (including the item, date on which the service was rendered and medicare number of the person in respect of whom the service was rendered) in relation to which the document, extract or copy is to be produced; and
(b) specify the reason or reasons for the CEO's concern that an amount paid, purportedly by way of benefit or payment under this Act, in respect of each such service may exceed the amount (if any) that should have been paid; and
(ba) specify the circumstances in which a determination may be made under subsection 129ACA(2) in relation to an amount; and
(bb) contain a statement that the person may provide a written response to the CEO which states:
(i) if the person considers a determination under subsection 129ACA(2) should, or should not, be made and the person's reasons for this; and
(ii) the percentage that the person considers should be determined for the purposes of paragraph 129ACA(3)(b); and
(bc) specify any matter, or contain any statement, prescribed by the Minister under paragraph 129ACA(9)(d); and
(c) specify the information relevant to ascertaining whether amounts paid in respect of each such service should have been paid; and
(d) specify how the document, extract or copy is to be produced; and
(e) contain a statement to the effect that the person to whom the notice is given is not expected to produce a document, extract or copy containing clinical details relating to an individual unless the document, extract or copy is necessary to ascertaining whether the amount paid in respect of the service should have been paid; and
(f) specify the period within which, and place at which, the document, extract or copy is to be produced.
The period specified under paragraph (f) must be a period ending at least 21 days after the day on which the notice is given.
Note: For the purpose of paragraphs (8)(b) and (c) the notice will include the reason for the CEO's concern about the payment and explain the factual issue that the person is required to substantiate.
Health information
(9) The power under this section to require a document, extract or copy to be produced includes the power to require the production of a document, extract or copy containing health information (within the meaning of the Privacy Act 1988 ) about an individual.
(9A) If requested to do so under subsection (3), a person is authorised to produce any document relevant to the request, including a document containing health information (within the meaning of the Privacy Act 1988 ) about an individual.
Clinical relevance of particular professional service not to be taken into account
(10) In forming a reasonable concern for the purposes of subsection (1), the CEO is not to take into account the clinical relevance of a particular professional service.
Giving notices to State and Territory Health Departments
(10A) If:
(a) either of the following is given to a person in relation to a professional service rendered by the person:
(i) a notice under subsection (2);
(ii) a written request mentioned in subsection (3); and
(b) the professional service was rendered, or purportedly rendered, in or at a hospital mentioned in subsection (10B) of a State or Territory;
then, a copy of the notice or request may be given to the head (however described) of the Health Department (within the meaning of the National Health Reform Act 2011 ) of that State or Territory.
(10B) For the purposes of subsection (10A), a hospital is a facility in that State or Territory for which:
(a) a declaration is in force under paragraph 121 - 5(6)(a) of the Private Health Insurance Act 2007 ; and
(b) a statement is included in the declaration (as mentioned in subsection 121 - 5(8) of that Act) that the hospital is a public hospital.
Section not limited
(11) This section is not limited by:
(a) any other provision of this Act; or
(b) any provision of the Human Services (Medicare) Act 1973 or any other Act;
that relates to the powers of the CEO to require the production of documents.