How To Improve The Department'S Compliance Program

Transcription

1 Compliance Program humanservices.gov.au

2 Our compliance approach to protecting the integrity of our payment system has the strong support of the government, as it underpins our fair social welfare and health systems. 2

3 Foreword from the Minister My department is now moving into its third year of providing a range of services that meet the needs of the Australian community for social, health, welfare and child support services. Recent changes to our service delivery model have shaped the way people engage with us and provided more streamlined services to make it easier for people to obtain payments and services. We aim to support people to meet their obligations when receiving social, health or welfare payments, or fulfil their obligations in making child support payments. We also assist health professionals to meet their obligations when claiming Medicare benefits or incentives, through ongoing education and stakeholder collaboration. Similarly, we assist businesses to meet their obligations under a variety of programs. The majority of people who deal with us are honest and want to do the right thing and the department works hard to support them in meeting their obligations In the coming financial years there are six main areas of focus for compliance activities. These efforts will further improve and protect the billions of dollars the department delivers to the Australian community to ensure we provide the right payment to the right person at the right time. The areas of focus are: using prevention and early intervention strategies contacting people in a variety of ways developing, testing and implementing new interventions reducing outstanding debt to government increasing fraud detection building our capability to detect new and emerging risks. We will continue to identify key risks associated with Medicare claiming and adopt a range of approaches including targeted education, audits and reviews. We work very closely with a wide range of stakeholders to ensure they are well informed on all aspects of our compliance approach. We will intervene quickly to correct payments when honest mistakes occur. We will continue to work with people who find themselves in debt, providing a range of support including financial assistance and counselling. We have also increased our efforts in detecting and taking action against those who intentionally engage in fraud. Apart from its utility as a strategic document, the Compliance Program supports the public, health professionals, businesses, community groups, the media and other government agencies to understand the department s efforts in protecting the integrity of Australia s welfare, health payment and services systems. The department appreciates the great trust and responsibility it has been given to protect the integrity of the services delivered to the Australian community. Senator the Hon Jan McLucas Minister for Human Services Compliance Program

4 Introducing the Department of Human Services The Department of Human Services (the department) delivers Medicare, Centrelink and Child Support payments and services. The department provides policy advice on service delivery matters to government to ensure effective, innovative and efficient implementation of government services. The priority is to give people access to welfare, health and other payments and services in ways that suits their circumstances. About this document This document outlines the key departmental compliance activities for Compliance activity is necessary to ensure that government outcomes are achieved. It plays an important role in addressing the department-wide strategic risk Failure to manage the integrity of government outlays. It supports the department s staff, the public, health professionals, businesses, community groups, the media and other government agencies to understand the importance of protecting the integrity of Australia s welfare, health payment and services systems. The range of people we support is diverse. We make payments to individuals that fall into a variety of groups such as students, working age people, families, older Australians, people with disability and veterans. We also make payments to: health professionals and allied health professionals including, for example, doctors, dentists and optometrists, pathology authorities, radiology practices, pharmacies and pharmacists businesses including, health insurance funds, users of the Tasmanian Freight Equalisation Scheme and contracted third-party organisations. As well, we take the lead role in assisting people affected by emergencies and natural disasters. The department s Compliance Program for covers: Our compliance priorities what the priority areas of compliance will be over the next two years. Our compliance approach outlines the department s strategic focus on early intervention and prevention to help people get their correct entitlements through to using the full force of the law to prosecute fraud. Our compliance model explains how the department uses a mix of compliance activities in response to all levels of non-compliance. Managing compliance details how the department minimises debt, detects incorrect payments, recovers outstanding debts and addresses fraud. Our targeted compliance strategies sets out how our compliance activities apply to either individuals or to specific groups, for example, families, older Australians, working age people, health professionals and businesses. This document provides an overview of the department s compliance strategies and activities. Any specific compliance action undertaken is tailored to particular cases. 4

5 Contents Foreword from the Minister 3 Introducing the Department of Human Services 4 About this document 4 Our compliance priorities 6 Our compliance approach 6 Our compliance model 7 Managing compliance 8 Understanding our risks and learning from experience... 8 Focusing on prevention and early intervention... 8 Checking information to minimise debt and overpayments... 9 Identifying, investigating and prosecuting fraud...10 Our targeted compliance strategies 12 Debt recovery...12 Managing debt...12 Compensation recovery...12 Individuals...13 Families...14 Separated families...16 Older Australians...19 People of working age...21 People with disability...21 Single parents...22 Students...22 Carers...23 Health professionals...24 Businesses...29 Contact us 30 Centrelink services...30 Child support services...30 Medicare services...30 Health professionals...30 Fraud Tip-off Line...31 Extra assistance when calling...31 Compliance Program

6 Our compliance priorities Our compliance approach Using prevention and early intervention strategies by providing information and education resources and by moving interventions closer to the point at which an error occurs. Contacting people in a variety of ways for example, we may use a range of targeted communication channels to contact people who we identify as needing to update their circumstances or who may have been overpaid and at risk of incurring a debt or health professionals whose claiming pattern is significantly different to that of their peers. Developing, testing and implementing new interventions to address risk associated with non-compliance, the department is working to increase its use of early intervention outbound calls and electronic messaging to educate and encourage people to meet their compliance requirements and reporting obligations. Reducing debt reducing outstanding debt to government through a range of strategies which include enhancing our departmental and cross-agency performance in both minimising overpayments and recovering debts as quickly as possible. Increasing fraud detection by working with others to ensure identity fraud, undeclared assets and income and unusual patterns of online activity are identified and by analysing data to identify high billing or unusual claiming patterns. Building our capability to detect new and emerging risks for example, by preventing and disrupting organised crime and systemic fraud before it becomes established in Australia s welfare and health support systems. The majority of people the department deals with are honest and want to comply with legislative and program requirements. We aim to support people to meet their obligations when receiving a social, health or welfare payment or to fulfil their obligations in making a child support payment. Our compliance approach protects the billions of dollars the department delivers to make sure we provide the right payment to the right person at the right time. This approach helps protect the integrity of our health, welfare and child support payment systems and our compliance approach responds to the needs of different groups of people who access our payments and services. Compliance strategies take account of a range of payments, services and health related benefits provided by the department, as well as the circumstances of individuals and health providers. Payment integrity means ensuring payments are being managed correctly and that appropriate checks exist to minimise the likelihood of errors. This has the strong support of government and the Australian people. We are focused on early intervention and prevention to help people get their correct entitlements and we assist health professionals to meet their obligations and responsibilities. We work with people to resolve any issues, if they have not complied with reporting requirements because of genuine mistakes. Where there is deliberate fraud, offenders may be prosecuted. The department continues to monitor and evaluate our approach to help shape future compliance activities. For separated parents accessing child support services, the compliance approach differs. The approach aims to reduce the rate of growth of child support debt by increasing the number of finalised debts. Although more parents now pay their child support in full and on time, strong detection and enforcement measures are still needed for parents who deliberately choose not to meet their child support obligations. 6

7 Our compliance model The department s compliance model recognises that most people want to provide correct and up-to-date information. A mix of compliance activities helps people to receive accurate payments and encourages them to meet their obligations. Changes to the department s service delivery model have shaped the way people engage with us and have provided more streamlined services to make it easier for them to access payments or services. Improved communication helps better understand how best to meet people s needs and prevent inaccuracies. The aim of the compliance model is to make it easy for people to do the right thing through education and other assistance. Our main priority remains to work with people to help them comply with their payment requirements and other obligations. This means educating people about what they need to tell us and how to avoid debts. To achieve this we provide information through various communication channels including letters, our website, mobile device apps, and via the media. Another key element of our compliance model is to quickly identify and contact people who need to update their circumstances or may have received overpayments. We also review people s entitlements and audit health professionals to ensure they are entitled to the amount they are receiving. The department s fraud control processes are designed to focus intelligence and investigation activity on the most serious cases of non-compliance rather than on those people making honest mistakes. Where there is suspected fraudulent activity we use a mix of sophisticated fraud investigation techniques, including advanced data analytics, profiling and working with law enforcement or regulatory agencies. This includes detecting organised and systemic fraud, identity fraud, undeclared assets and income, unusual patterns of online activity and high billing or unusual claiming patterns. Where fraud is identified we recover overpayments and refer serious matters for prosecution. The following diagram shows the strategies we use to respond from low through to high levels of compliance. Attitude to compliance Compliance strategy Have decided not to comply Use the full force of the law Don t want to comply Deter by detection Try to, but don t always succeed Help to comply Willing to do the right thing Make it easy Enhanced compliance outcomes Compliance Program

8 Managing compliance Understanding our risks and learning from experience Continually assessing, controlling and monitoring compliance risks are central to managing compliance. The department s priorities are to assess identified risks 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 in the welfare and health fields. We also consult with a wide range of stakeholders, such as community advisory groups, so that we can better understand factors that affect compliance. A key area of focus for the department is managing the risk associated with customers electing to manage their own business through self service channels. In response, we are identifying and implementing compliance strategies that complement the transition to online self service environments. Through risk assessment processes, intelligence gathering and post-case analysis, the department is able to see emerging patterns that allow us to learn from experience and use this knowledge to develop compliance responses. Focusing on prevention and early intervention The department continues its compliance transformation to a risk-based model that focuses on early intervention and prevention. Significant progress has been made in this transformation by establishing a risk-based business model and implementing a number of early intervention activities. This has led to new compliance interventions which educate, inform and assist people accessing payments and services. The department continues to use the latest technologies and self service applications to educate individuals, health professionals and businesses about their payments and obligations with less direct intervention from the department. Most people do the right thing and meet their obligations. We aim to prevent payment inaccuracy, rather than simply detect overpayments or non-compliance after the event. The department continues to educate people about their reporting obligations and increase the number of early and direct contacts we have with them. We contact individuals early in several ways. We phone people who we have identified as having a change in circumstances, like starting a new job or people who are falling behind in their child support payments. This early contact helps us to update our records, reduce debts, and reinforce the need for people to meet their reporting obligations. We send targeted feedback letters to health professionals about service levels and bulk billing incentive items. Early intervention activities continue to help parents fulfil their child support obligations to financially support their children and minimise unnecessary reliance on welfare support. 8

9 Checking information to minimise debt and overpayments We check information to ensure there are no discrepancies in the details people give us. If there is a discrepancy, we contact people to help them comply. As a result, we may stop payments, change the amount of payment and/or recover a debt. Data-matching We cross reference millions of records with data held by Australian Government departments and agencies, state and territory governments, financial institutions such as banks, and employment service providers. This is called data-matching. Using data-matching we check: income from employment, business, and investments departures and arrivals to/from Australia property and other assets superannuation details enrolment details with public and private education institutions identity and relationship status. Important: the department does not match personal health information records, or Pharmaceutical Benefits Scheme and Medical Benefits Schedule data. Data-matching is carried out in line with the Office of the Australian Information Commissioner guidelines and relevant legislation. Data analytics The department uses advanced data analytical techniques to find underlying patterns of incorrect payment and fraud. This involves sophisticated statistical and behavioural analysis and modelling to uncover patterns in data and identify those most at risk. We use data analytics to more effectively target our compliance and fraud control activities. The department undertakes data analytics across the health programs to detect new and emerging risks. This includes geospatial analysis of claims data and prediction of growth within programs to identify unusual areas of growth that may be due to noncompliant or opportunistic billing. Data analytics has expanded beyond analysing Medicare providers to include pharmacies and consumers. Future work in data analytics includes creating models which define the characteristics of high-risk entities. These characteristics help build risk profiles on individuals, health professionals and companies. The results of compliance activities from projects and tip-offs are used to refine existing systems and develop new detection techniques. Public tip-offs Reviewing people s payments resulting from tip-offs builds confidence in the integrity of the income support system. People can report suspected fraud via the Australian Government Services Fraud Tip-off Line on , or via the department s website at humanservices.gov.au/fraud Information from the public about people who may have incorrectly or fraudulently claimed or received a payment or benefit is used to review entitlements and, if appropriate, carry out investigations. Contacts from health professionals or the public about potential fraud relating to health care programs are individually assessed to determine whether an investigation is required. Allegations that indicate problems with patient safety are referred to the relevant authorities. Privacy legislation and secrecy provisions prevent the department from disclosing information about customers to the person providing the tip-off. This includes any review or investigation that may occur as a result of a tip-off. Although the department is unable to report the results of these reviews or investigations, this should not be taken as inactivity. The department matches data with state, territory and Australian Government agencies and also business entities to identify non-compliance. New data-sharing arrangements are being developed all the time. The department also continues to use information from the Australian Government Services Fraud Tip-off Line. Compliance Program

10 Identifying, investigating and prosecuting fraud Fraud is intentional non-compliance that results in a person receiving payments to which they are not entitled. Mistakes or inadvertent oversights are not considered to be fraud. A small number of people try to fraudulently exploit the system. If a person deliberately makes false or misleading statements or intentionally fails to report their circumstances to gain a financial advantage, the department takes action. This may include criminal prosecution. Cash economy Cash economy is defined as income producing activity that is not part of the regulated economy. Because people are tempted not to declare this extra income, the cash economy is a risk to payment accuracy. Declare your cash earnings or risk prosecution Mandy was receiving unemployment benefits. However, we found out that she was running a successful cleaning business and she was not reporting her income. When the Commonwealth Director of Public Prosecutions prosecuted Mandy, she pleaded guilty and was sentenced to six months jail and ordered to repay $ We support a whole-of-government approach to addressing risks associated with the cash economy. As a member of the Joint Agency Cash Economy Strategic Working Group with representatives from the Australian Taxation Office, the Department of Education, Employment and Workplace Relations and the Department of Immigration and Citizenship we keep up to date with the latest developments and investigation techniques. Organised and systemic fraud We have a strong focus on detecting and disrupting organised and systemic fraud. Organised and systemic fraud is planned and often involves groups of people working together to commit crime. We have one of the most sophisticated fraud detection and investigation systems in the world. We use our significant intelligence and investigative capability to ensure that people involved in organised and systemic welfare and health-related fraud are caught and prosecuted. Government funding has equipped the department with new systems, data sources and multi-disciplinary teams of investigators, financial and intelligence analysts. The department continues to expand its detection capabilities to prevent systemic and organised fraud becoming established in the welfare and health-related support systems. We work closely with the Australian Crime Commission, Australian Transaction Reports and Analysis Centre and other state, territory and Australian Government law enforcement agencies to combat organised crime. We regularly share information and intelligence with our law enforcement partners to assist governments to deal with organised crime in the community. Our cooperation has helped to disrupt and successfully investigate a number of individuals and groups involved in serious crimes including drug importation and money laundering. While we monitor many industries, cash payments in the transport, fruit picking and harvesting industries are of special interest. 10

11 Responding to fraudulent activity A small number of people deliberately try to exploit the department s payments and services. Our processes for selecting matters for investigation are carefully designed to target matters involving dishonesty or other types of criminal behaviour rather than mistakes. If an investigation finds the overpayment was due to an honest mistake, the matter ends with recovery of the debt. Investigations that reveal evidence of criminal behaviour are referred to the Commonwealth Director of Public Prosecutions. As well as having to repay a debt, fraudulent behaviour can lead to prosecution and imprisonment. The department is a member of the Heads of Commonwealth Operational Law Enforcement Agencies and an active member of the Australian Government law enforcement community. This enables us to contribute to a whole-of-government approach to targeting commonwealth fraud and actively participate in developing national crime assessments. The department is aware that people who behave fraudulently often find new ways to abuse the system. We work closely with state, territory and Australian Government law enforcement agencies to ensure we are aware of new or emerging techniques that may be used by offenders to fraudulently target the welfare system. We design specific projects to target evolving and emerging risks, such as working with business entities to detect undeclared income. Our investigations are conducted in line with the Australian Government Investigation Standards. We have Australian Federal Police officers out-posted to our investigation teams to guide, train and support staff. These officers also execute search warrants to support our investigations. The criteria we use to decide if an allegation warrants investigation include: the person s history of compliance the likely existence of criminality a consideration of whether investigation and possible prosecution is an appropriate response the dollar value of the fraud. In some cases we use optical surveillance specialists to provide video evidence of fraudulent behaviour. The department continues to enhance its serious non-compliance capability to investigate where there has been deliberate non-compliance in the Medicare program. This includes steps to improve our intelligence capability to identify and analyse cases for investigation. This ensures incidents of fraud are detected and appropriately investigated. Investigation and referral for prosecution of individuals or corporate entities who act fraudulently is a crucial element of our overall compliance response, serving as a deterrent for future fraudulent behaviour. The department is a member of the Heads of Commonwealth Operational Law Enforcement Agencies and an active member of the Australian Government law enforcement community. Compliance Program

12 Our targeted compliance strategies The range of people we support is diverse. For example, we make payments to individuals that fall into a variety of groups such as students, working age people, families, older Australians, people with disability and health professionals. As well, we take a lead role in assisting people affected by emergencies and natural disasters. Our interactions with employers are also important. For example, employers may withhold a separated person s wages to make sure child support payments are paid. Debt recovery The department is responsible for ensuring public funds are delivered correctly through social, welfare and health payment systems. Where possible we aim to prevent incorrect payments and claims. We use a range of measures to do this, including education, targeted early intervention and support to both customers and health professionals. Depending on the circumstances, we help people to make arrangements to repay money they were not entitled to and provide information to help them avoid debts in future. For people currently receiving a payment, the department will: reduce their payments to help repay the amount owing stop any advance payments. The rate of repayment can be varied in cases of financial hardship. For people who are not currently receiving a payment, the department has a range of choices to repay outstanding debts, including via: Australia Post BPAY direct debit cheque. When people are no longer receiving payments from the department and they do not enter into a voluntary repayment arrangement, the department can, where appropriate: refer their accounts to a collection agency take the debt out of their wages, tax refund and other assets and income (including money in their bank account) refer their case for legal action. Managing debt Specific debt management priorities for are to: develop and implement improvements to business processes and computer systems enhance the sophistication and availability of management information relating to debt, to better understand the causes and drivers of debt improve processes within the department to minimise debt creation and improve efficiency in debt raising and recovery. Compensation recovery Rules specific to compensation prevent people receiving both compensation payments and income support payments at the same time. The department takes compensation payments into account when assessing a person s eligibility for payments or benefits. Continuing periodic payments of compensation, such as weekly worker s compensation, reduces the payment amount received. If people fail to tell us about compensation payments, they may accumulate a debt to the department. Repaying debts from fortnightly payments Carlos owed the department $1500 in overpayments. A set amount started to come out of his fortnightly payments to repay the debt. However, he was having problems repaying the debt and we negotiated a new repayment arrangement so that he was not placed in severe financial hardship. 12

13 Individuals These compliance activities may apply to individuals who receive Medicare benefits, Centrelink payments, or to separated parents who pay or receive child support. Proof of identity Establishing the identity of our customers is an important aspect of maintaining the integrity of the department s services. Getting accurate proof of identity helps to correctly assess people s eligibility for assistance and reduce risks associated with identity fraud. In 2013, the department will sign on as a user of the Document Verification Service, giving us the capability to verify certain high-value identity credentials with the relevant issuer agency. The department continues to verify proof of identity and match records to reduce the risk of payment error. Identity fraud We use data analytics and other sources (such as the Australian Government Services Fraud Tip-off Line) to identify potential identity fraud. Identity-related fraud involves people using fake, manipulated, stolen or borrowed identities to fraudulently claim payments from the department. Our intelligence analysts and fraud investigators use advanced detection and investigation techniques to identify this type of fraud. The department continues to use sophisticated investigation methods and keeps up to date with the latest techniques to detect and investigate identity fraud. We are one of 13 Australian Government agencies that make up the Commonwealth Reference Group on identity crime. This group meets regularly to discuss operational issues, establish links, exchange information on trends, and keep up-to-date with the latest detection and investigation techniques and software. Using a fake identity to collect payments In , a man was jailed for 18 months for fraudulently collecting thousands of dollars in payments using a false identity. This was the man s first offence. He dishonestly collected payments for Disability Support Pension and Age Pension. Self service (online activity) We continue to enhance our self service channels to make it easier for people to manage their business with us. This includes people claiming benefits, updating their circumstances and reporting online, via mobile device apps and/or automated telephone Interactive Voice Response options. To ensure payment integrity, we use specific techniques that identify unusual patterns of online activity. Suspicious transactions are assessed by our intelligence teams and action is taken to address any suspected fraud. Leaving Australia If people leave Australia they may still be entitled to receive Centrelink payments. How long they continue to receive a payment depends on the time spent overseas, the type of payment, the country they are travelling to, how long they are going for and how long they have lived in Australia. The Department of Immigration and Citizenship provides the department with details of people leaving and entering Australia. We use this information to ensure payments are correct while recipients are outside Australia and after they return. In the case of parents with outstanding child support payments, we can issue departure prohibition orders which stops them leaving Australia until they pay their child support or make a suitable payment arrangement. We also have a Travelling with Pharmaceutical Benefits Scheme Medicine Enquiry Line and website with information to help individuals understand their rights and responsibilities when taking or sending Pharmaceutical Benefits Scheme medicines overseas. Assisting in emergencies To ensure that people receive their correct payment entitlement following emergencies, we use a range of sophisticated analytical tools, law enforcement data and investigation processes. We identify people who are at risk of non-compliance or risk of committing fraud. When necessary we intervene and take action to deal with individual cases. We also use risk profiling to identify high-risk claims. This approach is used when processing Australian Government Disaster Relief Payments. Compliance Program

14 Rent Assistance help with paying rent To ensure people receive the correct amount of Rent Assistance, they must verify their rent details and tell us if their housing circumstances change. Community housing organisations can verify their tenant s rent details electronically. Sometimes people sharing accommodation or living in relationships do not tell the department. These people are usually identified through data-matching and tip-offs. The department continues to contact people at risk of receiving incorrect Rent Assistance to ensure they get the correct entitlement. Death matching The department undertakes Payment After Death reviews by regularly data matching with state and territory registrar general offices to ensure as much as possible, that no payments are made, and that no inadvertent debt is accumulated or raised to the detriment of the person s estate, partner/spouse, trustee or person in a position to administer banking accounts. A deceased customer s estate, partner/spouse, trustee or person in a position to administer banking accounts of the deceased person may not be aware that payment of benefits must stop, or may not have remembered to notify the department that benefits need to stop. If benefits continue after the date of a death, they will accumulate a debt owed to the Commonwealth. Prescription information We provide national Prescription Shopping Information Services to health professionals to support their prescribing decisions in managing patients health care needs. Prescription shopping, also known as doctor shopping, is when patients knowingly or deliberately obtain more medicine than they may medically need. Families Reconciling Family Tax Benefit and Child Care Benefit A person s entitlement to Family Tax Benefit and/or Child Care Benefit is based on family income during a financial year. Families can choose to receive some, all or none of their entitlements during the year. These options give people flexibility to adjust their payments as their income and family circumstances change throughout the year. When people choose to receive Family Tax Benefit fortnightly and Child Care Benefit as reduced fees, we carry out end-of-year checking ( reconciliation ). This takes into account a person s actual income, rather than the estimate provided during the year. When Family Tax Benefit and Child Care Benefit payments are reconciled, the department can accurately assess a person s Family Tax Benefit and Child Care Benefit entitlements. We then tell people if they were overpaid or if they are entitled to top up payments. Overpayments of Family Tax Benefit and Child Care Benefit may be recovered from any future family assistance payments, supplement payments and tax refunds. Non-lodgement of tax returns We cannot reconcile Family Tax Benefit entitlements until the recipient and their partner (if they have one) have lodged their tax return(s) for the financial year or told us that lodgement is not required. People who are not required to lodge a tax return need to confirm their actual income with the department after the end of the financial year. People can do this either online, by phone or in person. People who do not lodge their tax returns may have a debt for all of the Family Tax Benefit they received in the financial year. As a result, fortnightly payment of Family Tax Benefit may also be stopped. Fortnightly payments are not re-started until the person has either paid off the debt, lodged all outstanding tax returns or told us they are not required to do so. 14

15 Lodging tax returns to get the correct amount of Family Tax Benefit Alice receives Family Tax Benefit for her children and provided an estimate at the beginning of of how much she thought she and her partner would earn over the coming year. In July 2011, Alice advised us that as she had not earned any taxable income for and that she did not need to lodge a tax return. Matthew, her partner, had worked and had to lodge a tax return. Alice was sent a reminder letter in April 2012 telling her that if Matthew s tax return was not lodged by 30 June 2012, she would have to pay back all of the Family Tax Benefit she received in , and her fortnightly payments may stop. By November 2012, Matthew still had not lodged his tax return. Alice was advised that she would have to pay back the Family Tax Benefit payments she received for , and her Family Tax Benefit payments would be stopped. Matthew then lodged his tax return. The Family Tax Benefit payments started up again, and because of their income for they were also eligible for a top-up payment. From , customers will have one year instead of two to lodge their tax return or advise that they are not required to lodge a tax return in order to receive any additional Family Tax Benefit entitlements. Compliance Program

16 Separated families Under child support arrangements, separated parents make payments for the benefit of their children. Our compliance strategy provides parents with the right balance of service, support, education and enforcement activities to help them meet their obligations. Most separated parents have private collection arrangements, which involve transferring payments between parents with little or no involvement from us. Parents can also choose to pay us directly and we will transfer payments between parents. Ensuring assessments of parental income are accurate Current Australian Taxation Office reported income is used to ensure children from separated families receive financial support in line with their parents financial capacity. When reported income details are not available, we determine an appropriate amount to be the paying parent s adjusted taxable income. If needed, we also work with the Australian Taxation Office to encourage people to lodge their tax returns. If a parent thinks their income will be less than the original estimate they gave us, they can contact us to have their child support assessment changed. Parents can also ask for a change of assessment if they have special circumstances that may make their current child support estimate unfair. The department encourages parents to lodge their tax returns to ensure our child support assessments are based on actual income. If a parent falls behind in their child support payments, we take action to get the payments up to date. Enforcing child support collection Some parents need more encouragement to meet their child support responsibilities. We can use a range of detection and enforcement measures to collect payments from parents who deliberately choose not to pay child support. When parents fail to comply with their obligations the department has statutory powers to obtain information for the purposes of assessing and collecting child support. We do this through a range of enforcement steps to ensure we achieve the best outcomes for the children. We can make an arrangement for an employer to deduct payments from a person s salary and wages and take enforcement action, including prosecution. We can deduct child support from Centrelink payments and some Department of Veterans Affairs benefits, or intercept a parent s tax refund to pay outstanding debts. We can also stop parents with child support debt from leaving Australia, and we can take a parent to court to force them to make their payments. The department continues to use our legal powers to enforce payment of outstanding child support payments. Taking action on outstanding child support We support parents who miss payments. If they miss one payment we contact the parent to talk about the reason they missed the payment and to remind them about their future child support responsibilities. If a parent falls behind with payments we make every attempt to contact them to negotiate an arrangement for outstanding child support payments. If parents do not make their payment by the due date a late payment penalty is applied. We may remove the penalties imposed on parents who do not pay on time if missed payments were beyond their control or if a parent agrees to clear all outstanding amounts and complies with this arrangement. 16

17 Detecting child support non-compliance Some parents structure their personal and financial affairs to avoid or minimise paying child support. By detecting such situations early, we can offer parents suitable options and information to achieve higher levels of compliance. To improve our detection of non-compliance, we continue to improve data-matching arrangements with partner agencies, promote the Australian Government Services Fraud Tip-off Line, build on our fraud detection and investigation activities (especially involving the cash economy and criminal activities) and work with banks and others to develop faster and more costeffective ways to gather information. The department will increase our focus on the small number of parents who actively avoid their child support responsibilities, especially people who evade them through the cash economy or through deliberate misrepresentation. Our compliance strategy provides parents with the right balance of service, support, education and enforcement activities to help them meet their obligations. Compliance Program

18 18 The department will continue to review and verify information from pensioners about their investments to ensure they get paid the right amount based on their income and assets.

19 Older Australians To qualify for the Age Pension, people must satisfy age and residence requirements. The amount of Age Pension they receive depends on the person s income, assets and other circumstances. To ensure that people receive their correct amount of pension, it is important that they tell us about any changes to their income or assets. We regularly contact people receiving Age Pension who identify as having extra income from investments that may affect their payment. We confirm information with the person, for example details of the number and type of shares or units they own or other investment account balances. This helps us to educate people about their reporting obligations. It also helps us to update their records to reduce the risk of any incorrect payment. The department continues to contact people who may not have reported owning investments, or changes to their investments, to remind them of their reporting obligations. Reviewing investments We have a comprehensive database of domestic and foreign shares, securities and managed investments. People who receive payments and who have financial investments need to keep us informed of which products and how many shares or units they own. They need to tell us about any changes to their financial investments including a sale, a purchase, a reinvestment plan, or a company takeover or rationalisation and how this has changed their investment. In the nine months to 31 March 2013, the department conducted interventions with customers to discuss their circumstances and remind them about their reporting obligations for income earning investments and assets. The department will continue to review and verify information from pensioners about their investments to ensure they get paid the right amount based on their income and assets. Pensioners with foreign pensions Some pensioners who have lived and worked outside Australia are eligible for social security benefits from another country. We prompt them to make a foreign pension claim when they are receiving an Australian pension. To work out a person s entitlement, each month any foreign income (including from foreign pensions) is converted to Australian dollars. Although we receive foreign pension details from some countries, people still need to tell us if their circumstances change. In the nine months to 31 March 2013, the department conducted interventions with customers to discuss their foreign pension details. The department will continue to contact customers who have not recently updated their foreign pension details to ensure ongoing compliance. We review any assets and income that payment recipients may have from a private trust or private company by assessing financial reports and any distributions they may have received. At the same time we also review the level of control that a person can exert over a trust or company, which may affect the amount of payment received. We also regularly review people who hold income stream products and also receive income support payments and concession cards. In , the department started data-matching with the Australian Taxation Office, specifically to review entitlement to Commonwealth Seniors Health Cards. The department will continue this activity to assist older Australians to comply with their income reporting requirements. Compliance Program

20 Pensioners living overseas Pensioners may choose to live overseas. As long as they continue to qualify, many pensioners may keep receiving Australian payments under portability rules or international social security agreements. The department will continue to review and assess whether people receiving foreign pensions in Australia and pensioners living overseas are paid correctly and continue to qualify for their Australian pension payments. We monitor overseas pensions by identifying when accounts are closed and payments are rejected. We also receive advice about a person s change of circumstances from other sources such as foreign social security agencies or Australian embassies. In the nine months to 31 March 2013, the department conducted interventions with 3575 customers living overseas to make sure they continued to qualify for their payments. The department will continue to contact customers living overseas to ensure ongoing compliance. Pensioners who also receive a payment from the Department of Veterans Affairs We match data with the Department of Veterans Affairs to identify people who may receive payments from both our organisations. Because people can move between receiving payments from us and the Department of Veterans Affairs we have a clearance process which prevents people getting two payments at once. We also update Department of Veterans Affairs payment information through data integrity checks. This is an automatic process that retrieves veterans payment information and compares it to the data held by the department. We follow up any discrepancies between the data. Aged care services We review claims for services provided to older Australians through Residential Aged Care Facilities and the Community Aged Care Program to check correct claiming. In particular we focus on correct recording of admission, discharge and leave dates to ensure correct payment is made. The department ensures that aged care providers receive correct payments. We continue to monitor the potential for incorrect claiming by community and residential aged care services. 20

21 People of working age Depending on their circumstances people of working age can receive either Newstart Allowance, Youth Allowance, Parenting Payment, Disability Support Pension or Sickness Allowance. The biggest risk to accurate payments is the correct reporting of their and their partner s (or parents ) earnings. Reporting earnings All customers receiving income support payments under the Social Security Act 1991 are by law required to report their earnings to the department. Debts incurred by people who have not reported their earnings correctly constitute the largest portion of the department s debt base. The department continues to explore innovative ways to help people keep details of their earnings up to date. We match data with a number of sources, including the Australian Taxation Office, to identify people who have recently started work and how much they have earned. We also monitor those who regularly report earnings to ensure they are reported correctly. The department uses promotion and education to reinforce the requirement to inform the department as soon as circumstances change, and to remind customers of their reporting obligations. The department also uses current and emerging technology to engage customers and make reporting easy. People can report using: a new Express Plus app using mobile device technology phone and online services in person at a department service centre. Tell us about paid work Tanya signed a Tax File Declaration form in late May We contacted her in early June 2013 to discuss her employment circumstances. She told the department she had started work and thought her employer would advise us. She provided details of her earnings and had to repay a small amount of her Centrelink payment. To avoid this happening again we explained how Tanya could report her earnings in future. We also suggested Tanya should look on our website for more information about reporting earnings. Early access to superannuation Sometimes working age people can access their superannuation on compassionate grounds or because of severe financial hardship. We help them do this and monitor arrangements to make sure they are not exploited. People with disability The department undertakes reviews of people who receive Disability Support Pension, particularly people who have undisclosed income, businesses or assets. We match data with external data sources to identify people at high risk of not accurately declaring the value of their assets, or under-declaring their income. If we think a Disability Support Pensioner s medical condition and/or capacity to work may have improved, we ask them to give us an update. We may then ask them to have a Job Capacity Assessment to find out if they should continue to receive Disability Support Pension. In the nine months to 31 March 2013, the department contacted customers through early intervention activity to discuss their commencement of work and educate them on reporting their earnings correctly. We have also started sending SMS messages to remind people who may have started work that they need to update their details. Compliance Program

22 Employed people and students with a temporary medical condition Sickness Allowance is a short-term payment for employed people and some full-time students who are temporarily unable to work or study because of a medical condition. From time to time, we request information from payment recipients, their doctor and their employer. This is to confirm that their medical condition still exists and is temporary and that they still have a job or study to return to. If any of these factors change the person may no longer be eligible for Sickness Allowance, but may be eligible for another payment. The department will use any new information about a person s medical condition to assess which payment best suits their circumstances. Single parents Parents claiming a payment as a single person must remember to tell us if their relationship status changes, as this may affect their payment rate. In some cases the department may ask for the names of independent referees to verify any changes in circumstances. The department will check if a single parent s relationship status has changed to ensure their payment is still correct. We use information matched with the Australian Taxation Office and other agencies, information generated by internal systems and information from the public, to identify people who claim to be single, but are actually in a relationship. Repaying a debt because of changed circumstances Maria is a single parent on a fortnightly Parenting Payment. In early August she moved in with a new partner. Maria did not tell us about this until December and in the meantime kept getting paid as a single parent. Because Maria delayed telling us about her changed circumstances, she had to repay a debt to the department, the amount of her ongoing payment was reduced, and the payment changed from Parenting Payment (Single) to Parenting Payment (Partnered). Students To receive a study-related payment from us, students have to stay enrolled in an approved course and undertake the required workload. Enrolment and attendance checks are made regularly through data matching with a range of educational institutions including universities, technical and further education providers, secondary schools and private education providers to confirm students who receive a study-related payment are receiving the correct amount. In the nine months to 31 March 2013, students had interventions conducted as a result of data-matching to discuss their study details. The department continues to work with educational institutions to ensure students get their correct entitlements. Enrolment details of university students receiving a study-related payment are exchanged with the department weekly to help reduce student debt. We have introduced mobile device apps that give students a convenient way of updating their study details and other changes in circumstances. Looking for work instead of studying Stewart is receiving Youth Allowance for studying law at university. The department sends a file to Stewart s university to confirm his study details. The university returns a file with Stewart s enrolment information which shows Stewart has withdrawn from his course. We contact Stewart, who says that he had forgotten to let us know and that he is now looking for work. We offer Stewart the opportunity to transfer to Newstart Allowance. Stewart may have a debt for any Youth Allowance payments that he was not entitled to receive after he withdrew from his studies at university. 22

23 Carers The department reviews people who receive Carer Payment and Carer Allowance to ensure they are still eligible to receive their payments. For example, people receiving Carer Payment must provide constant care on a daily basis and cannot take on permanent full-time paid work. Although carers have an obligation to notify us of any changes in their circumstances, we also carry out reviews of carers and the people they provide care for. By finding out about changes in circumstances early, we help carers avoid debts and encourage voluntary compliance. Reviews also assist in detecting payment fraud; for example, we may ask a carer whether they have stopped their caring responsibilities or had any changes to their income and assets. If they did not tell us about any changes to their circumstances, they have to pay back any money they were not entitled to. The department checks that carers continue to carry out their caring responsibilities while they are receiving carer payments. Compliance Program

24 Health professionals Compliance priorities for health professionals in are to: provide information, advice and education materials to help health professionals voluntarily comply with health and aged care program requirements, including information to reinforce that the department has obligations under the Financial Management and Accountability Act 1997 to pursue a debt where payments have been made incorrectly improve relationships and communication with stakeholders to better identify risks to compliance and to involve peak bodies when we are developing compliance strategies develop our intelligence and risk assessment processes to deliver targeted information, education services and health compliance activities work collaboratively with key government agencies, including the Department of Health and Ageing, to deliver targeted health compliance strategies and activities. In accordance with legislation, the department carries out various compliance activities. 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. Education To increase voluntary compliance among health professionals, the department s main approach is through education. We offer information and education through face-to-face and virtual delivery including elearning programs and reference material on our website for both new and experienced health professionals. This information helps health professionals understand their obligations and the requirements of Medicare and the Pharmaceutical Benefits Scheme. Compliance audits may also cover health and aged care support programs to ensure that practices and health organisations receiving incentive payments are eligible. 24

25 New health professionals New health professionals are less likely to be familiar with the requirements of the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. Because of this they may mistakenly claim or prescribe incorrectly. We provide a range of online education services, including elearning modules, quick reference guides, handbooks and other resources to help health professionals understand their obligations when working with the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. Claiming under Medicare The department conducts compliance audits with health professionals to verify details of services when there is a risk that payments are incorrect. If we find claiming that appears incorrect, health professionals are given the opportunity to respond. If an audit also identifies behaviour that may be fraudulent, a criminal investigation may result. Under Medicare: health professionals and third parties who hold relevant records can be compelled to produce documents to substantiate Medicare claiming health professionals may be liable for an administrative penalty where incorrect payments are made, notices to produce documents are not complied with, or services cannot be substantiated. Compliance audits may also cover health and aged care support programs to ensure that practices and health organisations receiving incentive payments are eligible. When an incorrect payment is confirmed, we are required to recover the money and provide advice and information to educate, support and encourage future voluntary compliance. The department carries out compliance audits to verify that services provided are eligible for payments and benefits. General practitioners and specialists We monitor areas where the pattern of general practitioner and specialist claiming differs significantly from their peers. These areas include: incorrect billing for example, billing for a similar but more complex or expensive item than the service provided, billing for a combination of items when one item covers the service provided, or billing for an additional consultation when the procedure includes consultation time incorrect prescribing, such as prescribing Pharmaceutical Benefits Scheme medicines to patients who do not meet the requirements inappropriate ordering and/or incorrect use of pathology and diagnostic imaging services consultations billed without the required referral or new referrals requested on top of an existing referral to allow the billing of another initial consultation. The department focuses on billing concerns, including: anaesthetic services referrals for specialist attendances skin items delivered by specialists services rendered by consultant psychiatrists. Practitioner Review Program This program reviews practitioners whose provision of services under Medicare and/or the Pharmaceutical Benefits Scheme suggests they may be engaged in inappropriate practice. Inappropriate practice includes providing services that are not clinically necessary, providing excessive numbers of services, and ordering too many tests. When any of these issues are identified, a departmental medical adviser (qualified practitioner) reviews the information. Usually the health professional is asked to explain and respond to any concerns. If their response is unsatisfactory, the department may refer the health professional to the Director of Professional Services Review (an independent agency) for further examination, with the potential for imposing sanctions. Compliance Program

26 80/20 business approach Under the Health Insurance Act 1973, a general practitioner or other health professional is deemed to have practised inappropriately if they have provided 80 or more professional attendances on each of 20 or more days over 12 months. This is to ensure that each patient receives adequate care. The department contacts health professionals identified as approaching the 80/20 service level to alert them to their daily service levels. When they have breached the 80/20 service level, the practitioner is referred to the Director of Professional Services Review. Bulk bill incentive items We examine payments for bulk bill incentive items to ensure these items are billed for eligible patients. The routine use of these items is examined where patients over the age of 16 years do not appear to have current concessional status. In , the department sent out targeted feedback letters to health professionals to remind them of their obligation to check that patients have current concessional status at the time of billing. We will continue to monitor claiming patterns for bulk bill incentive items and consider whether further compliance activity is required. Telehealth Telehealth is a program which delivers health services and information via telecommunication technologies. Telehealth provides financial incentives to eligible health professionals and aged care services who help patients participate in a video consultation called a Telehealth consultation with a specialist, consultant physician or consultant psychiatrist. The department carried out audits of health professionals billing Telehealth items in 2012 and found that a small number of health professionals did not satisfy the Medicare requirements for a Telehealth consultation which also affected their eligibility for the Telehealth On-Board financial incentive. The department will continue to monitor Telehealth services. Pharmacists We will continue to monitor payments made under the Fifth Community Pharmacy Agreement. Initiatives under the agreement aim to improve the quality use of medicine in the community and improve access to quality community pharmacy services in rural and remote areas. The department will continue to focus on: Residential Medication Management Reviews Home Medicine Reviews payment processes for pharmacy practice incentives. We will also continue to monitor approved suppliers making multiple claims for the same supply of a Pharmaceutical Benefits Scheme prescription. Where this results in an overpayment, we recover incorrect payments from the pharmacist. Breaking the Pharmaceutical Benefits Scheme rules A pharmacist admitted to claiming the Medscheck incentive (one of the new programs under the Fifth Community Pharmacy Agreement) without complying with the requirements of the program. The department raised a debt of over $ for incorrect claims. 26

27 Prescribers We continue to have concerns about high levels of prescribing medicines of potential addiction. We review prescribers who may be inappropriately prescribing and ask them for an explanation. The department will continue to focus on: prescribers who do not meet Pharmaceutical Benefits Scheme requirements general practitioners who inappropriately prescribe addictive medicines. Allied health professionals As part of our compliance approach we monitor and analyse claiming patterns to identify risks, concerns and areas of non-compliance and assist allied health professionals to understand their billing obligations. Approved pathology authorities The department monitors and may undertake compliance activities relating to the pathology sector. We will continue to consult with the Department of Health and Ageing in developing our compliance strategies. Radiology practices The department will continue to review radiology requester groups, specifically chiropractors and dentists, who have shown significant changes in their requests for diagnostic imaging services. The department will also monitor and review diagnostic imaging practices. We will continue to consult with the Department of Health and Ageing in developing our compliance strategies. We have an ongoing commitment to support allied health professionals. We publish education resources and work with allied health professionals and allied health peak bodies to identify the best ways to communicate with them. We continue to consult with the Department of Health and Ageing in developing our compliance strategies for allied health professionals. Optometrists Our compliance strategy for optometrists focuses on client over-servicing as a result of marketing and induction programs and billing certain computerised perimetry test (to find patterns of vision loss) items that do not meet the Medicare Benefits Schedule s item descriptor. Compliance Program

28 Chronic Disease Management items Payments to individuals for Medicare items are regularly monitored to ensure their correct use. Areas of focus include general practitioners referring ineligible patients under Medicare Benefits Schedule Chronic Disease Management items in order for patients to receive subsidised allied health services. We continue to collaborate with the Department of Health and Ageing to discuss future compliance activities that help health professionals understand Medicare requirements relating to care plans. The department will carry out further analysis of potential non-compliance to improve our education, audit and review activities for Chronic Disease Management items. Chronic Disease Dental Scheme The Chronic Disease Dental Scheme assisted patients with chronic medical conditions and complex care needs who were managed by a general practitioner. The scheme gave patients access to Medicare rebates for certain dental services. Under the scheme, a patient could be referred for dental services and receive up to $4250 in Medicare benefits every two years. Health support programs The department monitors and reviews payments made to practices and organisations receiving incentive payments, including their ability to continually meet eligibility guidelines. Incentive payments monitored by the department include: Practice Incentives Program (which includes incentives such as the Indigenous Health Incentive, Diabetes Incentive, Asthma Incentive and the Procedural GP Incentive) Mental Health Nurse Incentive Program Practice Nurse Incentive Program General Practice Rural Incentives Program. The department will continue to audit practices that have not returned annual confirmation statements to establish their continued eligibility to claim Practice Incentive Program payments. On 29 August 2012, the Minister for Health announced the scheme would be closed to new patients from 8 September 2012 and Medicare billing would cease for services provided after 30 November In the department will finalise all Chronic Disease Dental audits and deal with all complaints received. This involves making applications to the Minister for Finance and Deregulation for full or partial waivers in appropriate cases, consistent with the Government s intention to provide a more flexible approach to compliance with the scheme s requirements. The department continues to pursue all instances of inappropriate practice or fraud in the Chronic Disease Dental Scheme. These will remain subject to full debt recovery and, when necessary, referral to the appropriate authorities. 28

29 Businesses We review payments to health insurance funds made under the Private Health Insurance Rebate Program to ensure claims are correct. We also help to protect the integrity of the Tasmanian Freight Equalisation Scheme which assists the mining, agriculture, forestry and fishing industries with freight costs for non-bulk shipments across Bass Strait. As well, the department enters into contracts to share information with third-party organisations, for example, organisations that want to confirm people s eligibility for concessions or superannuation status. Third-party organisations can participate in the following programs administered by the department Centrepay, Confirmation eservices, Electronic Verification of Rent, Income Management Deductions and BasicsCard. The department will continue to review claims and implement risk-based compliance strategies for businesses that receive benefits or payments. We conduct periodic compliance checks to confirm that organisations are complying with the terms and conditions of their contract and to protect the integrity of the arrangements and payment systems. Our compliance checks operate under both tip-off and risk-based models. An organisation that is found to be non-compliant must take action to comply within a certain period. If they remain non-compliant their contract can be terminated. Compliance Program

30 Contact us Visit humanservices.gov.au for more information about payments and services or call the 13 or the 1800 number listed below that is most relevant to your situation. You can get general information about the services we provide by calling us on Note: Calls from your home phone to 13 numbers from anywhere in Australia are charged at a fixed rate. That rate may vary from the price of a local call and may also vary between phone service providers. Calls to 1800 numbers from your home phone are free. Calls from public and mobile phones may be timed and charged at a higher rate. Centrelink services Visit humanservices.gov.au/centrelink Employment Services Older Australians Disability, Sickness and Carers Families and Parents Youth and Students Income Reporting Drought and Farmers National Business Gateway International Indigenous Call Centre Freecall Income Management Line Freecall To speak to us in your own language about Centrelink services and payments, call us on Child support services Visit humanservices.gov.au/childsupport General enquiries Medicare services General public Visit humanservices.gov.au/medicare General enquiries Pharmaceutical Benefits Scheme (PBS) Visit humanservices.gov.au/pbs PBS general enquiries Travelling with PBS medicine enquiry line Health professionals Visit humanservices.gov.au/healthprofessionals [email protected] Medicare Provider Enquiry Line PBS Visit humanservices.gov.au/healthprofessionals then PBS [email protected] PBS general enquiries Prescription Shopping Information Service Authority prescription approval Department of Veterans Affairs authority prescription approval Practice Incentive Program (PIP) Visit humanservices.gov.au/healthprofessionals then Incentives and Allowances > Practice Incentives Program (PIP) PIP Rural Incentive Programs Visit humanservices.gov.au/healthprofessionals then Other programs information for health professionals > Rural Programs Rural Incentive Programs

31 Public Key Infrastructure (PKI) certificates Visit humanservices.gov.au/pki ebusiness Service Centre Online claiming and Electronic Claim Lodgement and Information Processing Service Environment (ECLIPSE) Visit humanservices.gov.au/healthprofessionals then Doing business with Medicare >Online business > ECLIPSE ebusiness Service Centre For more information about the Increased Medicare Compliance Audits initiative go to humanservices.gov.au/healthprofessionals then Doing business with Medicare > Compliance > IMCA Resources Fraud Tip-off Line The Australian Government Services Fraud Tip-off Line is for people to report suspected fraud against Centrelink, Child Support and Medicare services. Call the Australian Government Services Fraud Tip-off Line Extra assistance when calling For help with Medicare and child support services, call the Translating and Interpreting Service on TTY Enquiries for Centrelink, Medicare and Child Support Freecall Note: TTY is only for people who are deaf or who have a hearing or speech impairment. A TTY phone is required to use this service. The full range of health professional educational resources is available at humanservices.gov.au/hpeducation More information about the Practitioner Review Program is available at humanservices.gov.au/ healthprofessionals then Doing business with Medicare > Compliance > Practitioner Review Program Compliance Program

32 humanservices.gov.au