EXPLANATORY STATEMENT
Issued by the Minister for Health
Health Insurance Act 1973
Health Insurance (Approved Billing Agents) Instrument 2017
Authority
Subsection 20AB(6) of the Health Insurance Act 1973 (the Act) provides that the Minister may make Health Insurance (Approved Billing Agents) Instrument 2017 (the Instrument).
Purpose
Section 20AB of the Act relates to approved billing agents. Simplified billing is an initiative of the Australian Government and is administered by the Department of Human Services. Approved billing agents act on the patient’s behalf to claim un-paid, in-hospital Medicare and private health insurance medical benefits. The patient does not need to be involved in the process unless there is an agreed out-of-pocket expense. In order to be registered as an approved billing agent, prospective billing agents must submit an application to the Chief Executive Medicare for approval that meets the legislative requirements of the Act, the Instrument and the Health Insurance Regulations 1975. Once they are registered as an approved billing agent, legislation requires them to make an annual submission to the Chief Executive Medicare, in order to maintain their approval status. This Instrument does not introduce new requirements.
The creation of the Health Insurance (Approved Billing Agents) Instrument 2017 repeals the Health Insurance (Billing Agents – Conditions of Approval) Determination (No. 1) 2004 and the Health Insurance (Approval of Billing Agents) Guidelines (No.1) 2004 as both instruments are due to sunset on 1 October 2017.
Details
Details of the Instrument are set out in the Attachment.
Consultation
The assessment that the regulation is operating effectively and efficiently has been informed by a consultation process which involved subject matter experts in the Pharmacy and Insurance Branch, Medicare Benefits Schedule Policy and Specialist Services Branch and Advisings and Legislation Branch within the Department and the Payment and Claiming Branch at the Department of Human Services, over the period 19 July 2017 to 5 September 2017.
This Instrument replaces the Health Insurance (Approval of Billing Agents) Guidelines (No.1) 2004 and the Health Insurance (Billing Agents – Conditions of Approval) Determination
(No. 1) 2004.
This Instrument commences on the day after registration.
This Instrument is a legislative instrument for the purposes of the Legislation Act 2003.
ATTACHMENT
Details of the Health Insurance (Approved Billing Agents) Instrument 2017
Section 1 – Name of instrument
Section 1 of the instrument provides that it is the Health Insurance (Approved Billing Agents) Instrument 2017.
Section 2 - Commencement
Section 2 of the Instrument provides that it commences on the day after registration.
Section 3 – Repeal
Section 3 of the Instrument repeals the Health Insurance (Billing Agents – Conditions of Approval) Determination (No.1) 2004 and the Health Insurance (Approval of Billing Agents) Guidelines (No.1) 2004.
Section 4 – Authority
Section 4 of the Instrument provides that it is made under subsection 20AB(5) and 20AB(6) of the Health Insurance Act 1973.
Section 5 – Schedule
Section 5 of the Instrument provides that the Guidelines are made under subsection 20AB(6) of the Act for the purposes of subsection 20AB(3) of the Act.
Section 6 – Definitions
Section 6 of the Instrument notes the terms used in the legislative instrument.
Section 7 – Conditions of approval
Section 7 of the Instrument specifies the applicants must comply with the undertakings specified in Part 1.
Schedule - Guidelines
Part 1 – Criteria for Approval
Section 1 - Prohibited person not to be approved
Section 1 provides the conditions under which the Chief Executive Medicare must not approve an applicant.
Section 2 – Billing agent to give copy of annual report
Section 2 provides the requirements that a billing agent must provide the Chief Executive Medicare with an annual report outlining particular information and certification requirements.
Section 3 – Billing agent must keep trust account
Section 3 details the requirements the applicant must provide relating to a trust account.
Section 4 – Billing agent to give copy of certificate of incorporation
Section 4 states the Chief Executive Medicare must not approve an applicant that is a corporation, unless proof of incorporation is provided.
Section 5 – Approval to have force for 1 year
Section 5 provides that approval period for new applicants must not be longer than 1 year from the date of approval.
Section 6 – Undertakings to be given
Section 6 provides that the Chief Executive Medicare must not approve an applicant that has not provided the required undertakings in the approved form.
Part 2 – Undertakings by Applicant
Section 7 – Undertakings to be given effect
Section 7 provides the applicant, whether it is an individual, a corporation, or a partnership must undertake all reasonable steps to ensure compliance with the undertakings to the Chief Executive Medicare.
Section 8 – Keeping of records
Section 8 states that an applicant must retain copies of each assignment, and a record of financial accounts relating to each assignment, for 2 years after the day the assignment occurs.
Section 9 – Inspection of books and records
Section 9 specifies the people allowed to inspect an applicant’s books, records, and accounts, however this section does not permit non-consensual entry into premises to search and seize information.
Section 10 – Information about conduct of business
Section 10 specifies the details and information an applicant must provide in response to a written request from a Chief Executive Medicare officer.
Section 11 – Keeping of trust account
Section 11 specifies the appropriate conduct for how the trust account must be maintained and operated.
Section 12 – Claims lodged by registered organisations
Section 12 provides the specific conditions for a person to lodge a Medicare benefit claim on behalf of an applicant.
Section 13 – Patient’s statement of account
Section 13 specifies the requirements for the applicant to provide patients a statement of account and what the account must include.
Section 14 – Payment to an assigning practitioner – 90 day period
Section 14 states the timeframe for which a payment must be made to an assigning medical practitioner after the Chief Executive Medicare makes the payment.
Section 15 – Billing agent’s earnings
Section 15 states the applicant must only apply interest and charge commission on an amount paid into the trust account consistent with the agreement made with the relevant medical practitioner.
Section 16 – Privacy
Section 16 states that an applicant must comply with the Privacy Act 1988.
Section 17 – Changes in circumstances
Section 17 provides that the applicant must notify the Chief Executive Medicare of certain changes in circumstances.
Section 18 – Statement of activity
Section 18 details the requirements for an applicant to provide the Chief Executive Medicare a statement outlining their claiming activity within a specified timeframe.