Provider Factsheet - Documentation and Record Keeping
Compliance monitoring has identified evidence of poor record keeping by contracted service providers (providers). This compromises both the continuity of client care and provider’s ability to substantiate claims. Providers will be required to reimburse any unsubstantiated claims. The information below should assist to improve record keeping compliance.
Contracted Service Providers (providers) are required to create and maintain records for Hearing Services Program (program) clients, and if requested by the client forward the client file to another provider. They are also required to keep records of compliance with practitioner and site management.
Good documentation of client services and compliant record keeping ensures both the continuity of client care and the provider’s ability to substantiate program claims. Providers are required to reimburse unsubstantiated claims to the Commonwealth.
The Hearing Services Program (Voucher) Instrument 2019, Section 26 and the Service Provider Contract (the Contract), Clauses 11 and 13 require providers to
- make and maintain a complete, legible, accurate, current and comprehensive record for each voucher holder
- ensure the records are easily identifiable and accessible
- maintain records to support and substantiate all claims for payment
- retain the records for at least 7 years from the date of the most recent interaction with the client
- reimburse the Commonwealth and/or the client for payments received when the services were not provided in accordance with program requirements.
Service management records
The Hearing Services Program (Voucher) Instrument 2019, Section 38 and the Service Provider Contract (the Contract), Clauses 8, 10, 23 and Schedule A require providers to retain the following records for at least 7 years
- public liability, professional indemnity and workers compensation insurance certificates
- Practitioner Professional Body (PPB) membership certificates and certificates of competency
- supervision agreements for non-qualified practitioners
- ambient noise level and equipment calibration certification.
Tips to improve record keeping compliance
Providers must ensure
- you and your staff understand the program requirements
- all client notes and records are legible and have enough detail to verify the services delivered
- all client records are kept on the client file, or available on request
- the most current forms and guidance are used, as provided on the website
- information entered into the online portal matches the information on the client file.
Examples of non-compliance
- Unreadable file notes or use of tick boxes as the evidence
- Evidence that records have been altered, for example changing dates or using liquid paper on claim forms and case notes
- Inconsistent dating in case notes, audiograms, NOAH data and other documents
- Incomplete, unsigned or missing forms, e.g. claim forms, WANT forms and device quotes
- Inconsistencies between client file information and details entered into the online portal, particularly 3 Frequency Average Hearing Loss (3FAHL) results and costs to client
- Insufficient evidence that the full services required for a claim have been completed
- Failure to retain Practitioner Professional Body (PPB) certification for practitioners
- Ambient noise level and equipment calibration certifications not kept up-to-date or not assessed under the correct Australian Standard.
Program requirements are monitored in accordance with the programs’ Compliance Monitoring and Support Framework. Please note that if any invalid claims are identified, providers must reimburse the Commonwealth and may be required to reimburse clients.