Changes to Record Keeping requirements under HIA (Word 19 KB)
Changes to Record Keeping requirements under HIA (PDF 431 KB)

The Health Legislation Amendment (Improved Medicare Compliance and Other Measures) Act 2018 came in to effect on 1 July 2018 and places a number of new requirements on health practitioners claiming Medicare Benefits Schedule (MBS) items, including record keeping obligations.

From 1 July 2018 the following requirements apply:

Referrals

Allied health practitioners

From 1 July 2018, allied health practitioners (with the exception of optometrists) must keep copies of referrals for two years from the date of the service.

This means that if a patient claims an item and receives a referral to see an allied health practitioner, that allied health practitioner is required to keep a copy of the referral for two years from the date they provided the first MBS service to the patient under that referral.

Specialists and consultant physicians

From 1 July 2018, specialists and consultant physicians must keep copies of patient referrals for two years from the date of service.

This means that if a patient claims an item and receives a referral to a specialist or consultant physician, that practitioner must keep copies of the patient referral for two years, from the date of the first MBS service provided by them to the patient under that referral.

Plans required to be created as a condition of claiming an MBS item

Practitioners will be required to keep copies of any plans that are created as a condition of claiming the MBS item for two years from the date of the professional service.

Examples of such plans include:

- GP Chronic Disease Management plan (required to be created under MBS item 721)
- GP Mental Health Plan (required to be created under MBS items 2700, 2701, 2715 or 2717)
- Consultant physician treatment and management plan (required to be created under item 132)

This means that if a patient claims an item such as those mentioned above, and the practitioner prepares such a plan as required by the MBS item, the GP must keep a copy of the plan for two years from the date that it was prepared.

Summary of new requirements

Before 1 July 2018	From 1 July 2018
Specialists and consultant physicians are required to keep copies of referrals for 18 months	Specialists and consultant physicians are required to keep copies of referrals for two years
Pathologists and radiologists are required to keep copies of referrals for 18 months	Pathologists and radiologists are required to keep copies of referrals for two years
There is no requirement for allied health practitioners to keep copies of referrals	Allied health practitioners (other than optometrists) are required to keep copies of referrals for two years
The payment of a rebate for a professional service may be conditional on the creation of a document, but there is no requirement for a practitioner to keep a copy of the document	If a document is specifically mentioned in an item (such as a GP Health Assessment), and is created by the practitioner, then the practitioner must keep a copy for two years