Claims Reimbursements

The Department of Health (the Department) has a responsibility to provide assurance to the Australian community that Commonwealth funds are managed in accordance with the Public Governance, Performance and Accountability Act 2013 (PGPA Act).

In the case of the Hearing Services program, in return for Commonwealth funding providers are expected to provide services in accordance with

• the Hearing Services Administration Act 1997 (the Act)
• the Hearing Services Program (Voucher) Instrument 2019 (the Instrument)
• the Service Provider Contract (the Contract)
  • Schedule of Service Items
  • Schedule of Fees and the associated program standards
  • Hearing Rehabilitation Outcomes (HROs)
  • Minimum Hearing Loss Threshold Guidelines (MHLT)
  • Eligibility Criteria for Refitting (ECRs).

Under Section 23 of the Act, a provider is liable to repay the Commonwealth where these requirements have not been met. This is known as a claim reimbursement. Section 24 of the Act deems this a debt due to the Commonwealth. Clause 13 of the Contract states that providers must reimburse the Commonwealth for claimed services that were not provided in accordance with the Act, the Contract or the Schedule of Service Items and Fees.

The Department is accountable under the PGPA Act to pursue recovery of each debt for which it is responsible.

 The objectives of claim reimbursements are

• to recover incorrectly claimed government funds
• to encourage appropriate claiming and
• to ensure client claiming history reflects the correct claims.

Incorrect claims can be identified by the provider or by program staff during compliance monitoring activities, and may include

Invalid Claims - Claims that were not compliant with the Act, the Instrument, the Contract, the Schedule of Service Items and Fees, and/or the program’s standards. For example, services were provided outside the voucher period, clients were refitted with devices without meeting the ECRs, binaural maintenance claims were paid where the client is monaurally fitted or the MHLT exemption criteria were not met.

Unsubstantiated Claims - Claims where the provider was not able to show sufficient evidence that the requirements for the claim had been met. For example, the client file notes did not outline the information required to show that a complete assessment was undertaken and that the client’s goals, needs and motivations were discussed.

How to process reimbursements

Incorrect claims identified during compliance monitoring activities, such as audits, will be processed as part of that activity.

All other reimbursements must be processed through the online portal.  Information on how to process these is available in the HSO User Guide - Hearing Service Providers.  

For provider initiated recoveries, if the client is no longer attached to your business, email hearing@health.gov.au with the client details, item number, date of service and the reason the reimbursement is required.

Any debt owing to the Commonwealth will be deducted from any future payments due to the provider as specified in clause 13 of the Contract. Debt recovery action can also proceed.