EXPLANATORY STATEMENT
STATUTORY RULES 1983 NOS. 255 and 254
ISSUED BY THE AUTHORITY OF THE MINISTER FOR HEALTH
HEALTH INSURANCE ACT 1973
HEALTH INSURANCE REGULATIONS (AMENDMENT) No. 255
HEALTH INSURANCE (PATHOLOGY SERVICES) REGULATIONS
(AMENDMENT) No. 254
Sub-section 133(1) of the Health Insurance 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 which are necessary or convenient to be prescribed for carrying out or giving effect to the Act.
Section 7 of the Health Legislation Amendment Act 1982, which is yet to come into effect, will, when it does so, amend section 19 of the Health Insurance Act 1973 by inserting a new sub-section 19(6). The new sub-section 19(6) will provide that a medicare benefit is not payable in respect of a professional service unless there is recorded on the relevant account or receipt or, if an agreement to assign the benefit has been made, on that form of agreement, such particulars as are prescribed in relation to professional services generally or in relation to a class of professional services in which that professional service is included. It is intended that sub-section 19(6) will be brought into effect by Proclamation on 1 February 1984.
Health Insurance Regulations (Amendment)
These proposed Regulations will, by virtue of section 4 of the Acts Interpretation Act 1901, come into effect at the same time at which the new sub-section 19(6) takes effect, and will prescribe particulars for the purpose of sub-section 19(6). In respect of professional services generally, the following particulars will be prescribed:
• the name of the patient;
• the date on which the service was rendered;
• a brief description of the service in question;
• where the service was rendered by a specialist to whom the patient had been referred by a medical practitioner, the name of the referring practitioner and the number of the referral form furnished by the referring practitioner under regulation 10 of the Health Insurance Regulations.
With respect to professional services to which an item in Part 1 of the Table of Medical Services (the Table) relates (professional attendances not covered elsewhere in the Table), where a practitioner or participating optometrist attended a person on more than one occasion on the same day and on each occasion rendered such a professional service on that person, the time at which each such attendance on that day commenced shall be a prescribed particular for the purposes of sub-section 19(6).
With respect to professional services other than those to which an item in Part 7 (other than Division 9), 8, 8A, 9A or 11 relates (radiology services, radiotherapy services, nuclear medicine services and most pathology services), the following details will be prescribed particulars for the purposes of sub-section 19(6):
• name of the practitioner or participating optometrist who rendered the service;
• address of the place of practice at which the service was rendered;
• a statement by the practitioner or participating optometrist that the service was in fact rendered by him;
• where the service was rendered at a place of practice in respect of which the practitioner or participating optometrist has been allocated a provider number - that provider number;
• where the service was rendered on behalf of a participating optometrist by an optometrist who has not been allocated a provider number - the provider number of the participating optometrist on whose behalf the service was rendered; and
• where neither of the two situations outlined immediately above are relevant - the provider number allocated to the practitioner or participating optometrist in respect of any place at which he practices.
Where a practitioner or participating optometrist referred to in the paragraph immediately above is not the person who -
(a) is claiming or receiving payment of the fees in respect of the professional service in question; or
(b) where an assignment of medicare benefit has been made under section 20A of the Act, is the assignee of the benefit;
the name, address of the place of practice, and provider number of that person will be prescribed particulars.
With respect to professional services to which an item in Part 7 (other than Division 9) 8, 8A, 9A or 11 of the table relates, the name, address of the place of practice, and provider number of the practitioner or approved pathology practitioner will be prescribed particulars for the purposes of sub-section 19(6) where:
• the practitioner or approved pathology practitioner is claiming or receiving payment of the fees in respect of the service; or
• an assignment has been made or an agreement entered into in accordance with section 20A of the Act with respect to the medicare benefit payable in respect of the service, and the practitioner or approved pathology practitioner is the assignee.
With respect to the rendering of pathology services, the following details will also be prescribed particulars for the purposes of sub-section 19(6):
(a) where paragraph 16A(1)(a) of the Act applies to the service -
• the name and provider number of the practitioner who determined that the service was necessary;
• the date on which the practitioner determined that the service was necessary; and
• if the service was rendered under the supervision of an employee (who is a medical practitioner) of an approved pathology practitioner (who is not a medical practitioner), the name and provider number of that employee.
(b) where paragraph 16A(1)(b) of the Act applies to the service -
• if the service was determined to be necessary by an employee (who is a medical practitioner) of the approved pathology practitioner by whom or on whose behalf the service was rendered - the employee’s name and provider number; and
• if the service was determined to be necessary by the person performing the service - the initials ‘s.d.’.
(c) where paragraph 16A(1)(c) of the Act applies to the service -
• if the service was rendered in pursuance of a request made by the person who determined that the service was necessary, being a medical practitioner, who, at that time, was a member of a group of practitioners of which the practitioner who rendered the service was also a member - the date on which the abovementioned request was made and the name of the practitioner who determined that the service was necessary.
Health Insurance (Pathology) Services Regulations (Amendment)
Paragraph 16A(1)(a) of the Act provides that a Commonwealth medical benefit is not payable in respect of a pathology service unless a practitioner determined that the service was necessary and, in the case of a pathology service other than a prescribed pathology service or a service to which paragraph 16A(1)(b) applies, the service was rendered by an approved pathology practiioner in pursuance of a request addressed to him by a practitioner - being a request made in writing as prescribed. Regulation 5 of the Health Insurance (Pathology Services) Regulations currently prescribes the details which such a request is required to contain. The proposed Health Insurance (Pathology Services) Regulations (Amendment), will, in short, amend Regulation 5 to require the following details to be included on the request:
• the address and provider number of the requesting practitioner;
• an indication as to whether, at the time the request was made, the person was a hospital patient in a recognised hospital, a private patient in a recognised hospital or a private patient in a private hospital; and
• a description of the service to which the request relates sufficient to identify the item that relates to that service and the number of that item.
The proposed Regulations also provide that the term ‘provider number’ shall have the same meaning as in the Health Insurance Regulations. These Regulations will also come into effect on 1 February 1984.
These Regulations have, in essence, been introduced to ensure, in the light of the current trend towards incorporation of medical practices, that practitioners remain, for medical benefits purposes, personally responsible for their professional actions and individually subject to the legislative provisions relating to fraud and over-servicing. By improving the quality and accuracy of information available to the Government concerning practitioner’s practice patterns and provision of medical services generally, the Government’s ability to detect and contain the incidence of fraud and overservicing will be greatly enhanced.