EXPLANATORY STATEMENT
STATUTORY RULES 1983 NO. 70
HEALTH INSURANCE COMMISSION ACT 1973
HEALTH INSURANCE COMMISSION REGULATIONS (AMENDMENT)
Issued by Authority of the Minister for Health
Section 44 of the Health Insurance Commission Act 1973 (‘the Act’) provides that the Governor-General may make regulations, not inconsistent with the Act, prescribing all matters required or permitted by the Act to be prescribed or necessary or convenient to be prescribed for carrying out or giving effect to the Act.
Parts II and IIA of the Act respectively set out the functions of the Health Insurance Commission (“the Commission”) in relation to the medicare scheme and the conduct of medibank private. Sub-section 8E(1) in Part IIB of the Act provides that in addition the Commission shall perform such functions in relation to health insurance as are prescribed and such functions in relation to other matters relating to health as are prescribed.
The purpose of the regulations is to prescribe, for the purposes of sub-section 8E(1) of the Act, additional functions to be performed by the Commission.
Broadly speaking, these additional functions, previously carried out by the Department of Health, relate to the investigation and general control of the overall incidence of medicare fraud and over-servicing.
More specifically these functions are as follows:
• the devising and implementation of measures designed to -
i) control and reduce the incidence of over-servicing on the part of medical and dental practitioners and optometrists;
ii) facilitate the detection of such cases of overservicing; and
iii) prevent or facilitate the detection of fraudulent medicare benefit claims;
• the investigation of cases of suspected over-servicing and referral, where appropriate, of them to the Minister for Health for further action;
• the investigation of suspected cases of fraudulent medicare benefit claims and other offences against provisions of the Health Insurance Act 1973 or the Crimes Act 1914;
• the administrative duties involved in the implementation and operation of the provisions of the Health Insurance Act 1973 relating to the disqualification, for medicare benefit purposes, of practitioners found guilty of fraud;
• the provision of clerical and administrative services involved in the operation of the various Medical and Optometrical Services Committees of Inquiry established under the Health Insurance Act 1973; and
• the undertaking of action, on behalf of the Commonwealth, to recover from a person an amount of medicare benefit that is legally recoverable by the Commonwealth from that person.
The reason for the transfer of these functions is:
• to give effect to the principle that all operational aspects of medicare should be brought together under one administration; and
• to eliminate overlap between the Department of Health and the Health Insurance Commission in such areas as data handling, contact with members of the medical profession, and fraud investigation.
Details of the regulations are as follows:
Regulation 1 provides that the regulations come into operation on 20 May 1985; and
Regulation 2 prescribes the new functions that are to be performed by the Commission.
Overview
The Health Insurance Commission Act 1973 was enacted to establish the Health Insurance Commission and set out its functions, particularly in relation to the Medicare scheme and the operation of Medibank Private. The Act was intended to address the need for a unified administrative body to manage the complexities of health insurance within Australia. The Parliament of Australia introduced this legislation to streamline health insurance administration and ensure that all operational aspects of Medicare are efficiently managed. The Health Insurance Commission Regulations (Amendment) issued under the authority of the Minister for Health in 1985, further defined the Commission's role by transferring additional functions from the Department of Health to the Commission, with a policy objective of integrating all aspects of Medicare under one administration and reducing overlaps in data handling, professional engagement, and fraud investigation between the Department and the Commission.
Scope and Application
The Health Insurance Commission Regulations (Amendment) aim to expand the functions of the Health Insurance Commission in relation to health insurance and the Medicare scheme. These regulations, made under section 44 of the Health Insurance Commission Act 1973, outline additional duties for the Commission, primarily focusing on the investigation and control of Medicare fraud and over-servicing. This includes devising measures to control and reduce over-servicing by medical and dental practitioners and optometrists, detecting such cases, and preventing fraudulent Medicare benefit claims. The Commission is also tasked with investigating suspected cases of over-servicing and fraud, referring significant cases to the Minister for Health, and managing administrative duties related to disqualifying fraudulent practitioners from Medicare benefits. These regulations apply to the Commonwealth jurisdiction and affect medical and dental practitioners, optometrists, and other entities involved in Medicare transactions. The scope of these regulations extends to the operational aspects of Medicare, aiming to streamline administration and eliminate overlaps between the Department of Health and the Health Insurance Commission.
Key Provisions
The Health Insurance Commission Regulations (Amendment) under the Health Insurance Commission Act 1973 primarily establish new functions for the Health Insurance Commission (the Commission). These functions are detailed in Regulation 2 and encompass measures to control and reduce over-servicing and fraudulent claims within the Medicare scheme, as well as the investigation and administrative duties related to such activities (Reg. 2). These provisions are essential for ensuring the integrity and efficiency of the Medicare system by targeting areas such as the management of medical, dental, and optometrical services, as well as the oversight of practitioner conduct.
The obligations imposed on the Commission by these regulations include the implementation of strategies to combat over-servicing and fraud, conducting thorough investigations into suspected cases, and collaborating with relevant authorities to facilitate the recovery of fraudulent benefits. Furthermore, the Commission is tasked with the administrative duties involved in disqualifying practitioners found guilty of fraud and providing necessary clerical and administrative support to various medical and optometrical services committees. These duties are designed to streamline the administrative processes and ensure compliance with the provisions of the Health Insurance Act 1973 (Reg. 2).
Failure to adhere to the requirements set forth by these regulations may result in legal consequences. While the specific offences, penalties, or civil and criminal consequences are not explicitly detailed in the provided explanatory statement, it is implied that breaches of these regulations could lead to legal action. The Health Insurance Commission Act 1973 and associated Acts, such as the Crimes Act 1914, provide frameworks for penalties related to fraudulent activities and misconduct in health services. Typically, penalties for such breaches can include fines, imprisonment, or other sanctions as prescribed by relevant legislation, reflecting the seriousness of maintaining the integrity of the Medicare system.