Australian Government - Department of Health - Office of Hearing Services
Hearing Services Program

Compliance Monitoring and Support Framework

The program’s approach to compliance monitoring, support and actions is detailed in the Compliance Monitoring and Support Framework. Program compliance is actively monitored, starting with provider accreditation, through contract management, complaints, claims audits, audits and compliance action and follow-up.

The aims of the program’s compliance activities are to

  1. protect client safety and provide quality outcomes for clients
  2. maintain program integrity
  3. ensure appropriate financial management of public expenditure that supports the program and
  4. safeguard Commonwealth records.

The program’s approach to auditing and compliance monitoring is based on several key principles

  • decision making is risk-based
  • the severity of the action taken is proportionate to the seriousness of the non-compliance
  • availability of clear and transparent guidance on the approach
  • accountability for client outcomes and safety, Commonwealth funds, and program integrity
  • timeliness of compliance monitoring and actions
  • the response to non-compliance is consistent and
  • consistant, fair and reasonable responses to non-compliance.

To assess and monitor compliance risks, a wide range of data and information sources is reviewed including

  • Hearing Services Online data.
  • Claiming data.
  • Complaints from clients, the public or health/hearing professionals.
  • Contract management issues.
  • Previous compliance actions, including audit outcomes.
  • Outcomes of the annual self-assessment process.

Key elements of the Framework include

  • a risk-based approach to monitoring compliance, focusing resources on the highest priority risks and issues
  • provider self-assessment of their compliance using the annual Self Assessment Tool (SAT) to assist in the identification of any areas of non-compliance with the program requirements. Provider self-assessment provides a timely, structured opportunity for providers to review the program requirements, critically examine their own systems and processes, and take action to address any areas of non-compliance
  •  the review and management of complaints about providers and their delivery of program services
  •  the analysis of program data and risk indicators to identify signals of non-compliance
  • the development of a risk-based schedule of audit activity which includes flexibility so that unscheduled activities may be undertaken to address new or changed regulatory risks as they are identified
  •  routine and regular reviews of claims data and patterns, with providers given an opportunity to review any irregularities identified from the claims audits
  • targeted and random audits in response to signals of non-compliance;
  • providers are given an opportunity to address the identified issues and to outline a plan of how the issues have been or will be addressed
  • the requirement for providers to reimburse unsubstantiated or invalid claims to the Commonwealth. Any payments made to providers for services not delivered in accordance with the program requirements must be reimbursed to the Commonwealth (refer clause 12 of the Service Provider Contract (the Contract))
  • provider reimbursement of unsubstantiated or incorrect payments received from clients. Any payments collected from clients for services not delivered in accordance with the program requirements, must be reimbursed to the client (Rule 28.3 of the Rules of Conduct 2012) and
  • more serious actions, as described in Chapter 8 of the Framework, may be implemented in serious cases of non-compliance, such as when client safety or program integrity is at high risk or when there is evidence of fraud.

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Framework Overview

The Framework describes

•         the objectives and legislated and contractual authority for compliance monitoring (Chapters 1 and 2)
•         the principles that underpin the approach to compliance monitoring and support (Chapter 3)
•         the risk assessment methodology used to determine compliance monitoring priorities (Chapters 4 and 5)
•         the role that provider self-assessment plays in compliance monitoring (Chapter 6)
•         the types of audit activities that may be carried out (Chapter 7)
•         the circumstances whereby various types of compliance actions may be taken (Chapter 8) and how the program monitors, reviews and continuously improves its approach to compliance monitoring (Chapter 9), including opportunities for providers to give feedback about the Framework and the program compliance monitoring activities.

An overview of the Framework processes are outlined in Diagram one below

Diagram 1 - An overview of the compliance monitoring processes.

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Compliance Actions

An overview of the approach to compliance is provided in Diagram Two - Compliance Monitoring and Support Pyramid. The pyramid outlines the types of actions that can be implemented to manage risk and respond to non-compliance, depending on the levels of non-compliance found and a provider’s willingness and capacity to address the identified issues. Where consistently high levels of compliance are demonstrated, providers earn a level of autonomy whereby minimal compliance monitoring is required. As the risk of non-compliance increases, non-compliance is identified and/or additional support is required, the level of compliance actions taken also increases. Full details of the compliance actions are outlined in the Framework.

As part of the risk-based approach to compliance monitoring, all providers must complete an annual self-assessment of their compliance with the program requirements. More information is available about the self-assessment process, including a link to the most recent Self Assessment Tool (SAT).

As specified in clause 12 of the Contract, providers must reimburse the Commonwealth for services that were not provided in accordance with the legislation, the Contract or the associated standards. Any invalid or unsubstantiated claims must be reimbursed. Further information on reimbursements is available.

Diagram Two Compliance Monitoring and Support Pyramid

This image outlines the differnt actions taken when non-compliance is identified, taking into account the provider's willingness to comply and assistance needed.

There are a range of compliance supports available to assist providers to comply with the program requirements.
 

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Compliance Monitoring and Support Framework (DOC 944 KB)

Compliance Monitoring and Support Framework (PDF 684 KB)

Compliance Monitoring and Support Factsheet (PDF 385 KB)

Compliance Monitoring and Support Framework

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