EXPLANATORY STATEMENT
STATUTORY RULES 1987 NO.33
ISSUED BY AUTHORITY OF THE MINISTER FOR HEALTH
HEALTH INSURANCE ACT 1973
HEALTH INSURANCE (VARIATION OF FEES AND MEDICAL SERVICES) (NO. 46) REGULATIONS
Section 133 of the Health Insurance Act 1973 (“the Act”) provides in part 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.
Section 9 of the Act provides that medicare benefits shall be calculated by reference to the fees for medical services set out in the table of general medical services in Schedule 1 to the Act. Schedule 1 contains items setting out the description of each medical service, the fee for the calculation of medicare benefit applicable in each State and rules for the interpretation of the table.
Section 4 of the Act provides that the table of general medical
services may be varied or replaced by regulations. The Health Insurance (Variation of Fees and Medical Services) (No. 44) Regulations, as amended, prescribe the present table of general medical services pursuant to section 4 of the Act.
The Minister for Health has agreed to certain recommendations which have been made by the Medicare Benefits Review Committee, which was established in part to recommend measures to encourage the provision of efficient and appropriate health care. The Committee has made several recommendations which are intended to simplify the process by which referrals are conducted to a consultant physician or a specialist.
At present, rule 3 of the rules for the interpretation of the table of general medical services is the main provision dealing with the circumstances in which a referral to a consultant physician or a specialist may be made. In order to implement the recommendations of the Medicare Benefits Review Committee, the Health Insurance (Variation of Fees and Medical Services) (No. 46) Regulations amend the rules for interpretation to provide for three new alternative systems of referral. The first is the preparation of a formal letter of referral. The second is the making of an informal written communication. The third is the making of an oral request.
The rules for interpretation are also amended to provide
for situations where a written referral has been prepared but has subsequently been lost, stolen or destroyed, and where a service is rendered by a consultant physician or a specialist and where the consultant physician or specialist forms the opinion that it is necessary that the service be rendered as quickly as possible.
The rules for interpretation are also amended to implement the recommendation of the Committee that the period during which a referral may authorise treatment should be limited to a maximum of 12 months.
Regulation 2 provides for the regulations to come into operation on 7 March 1987.
Overview
The Health Insurance (Variation of Fees and Medical Services) (No. 46) Regulations 1987 were enacted under the authority of the Health Insurance Act 1973. These regulations were introduced to address the need for streamlined and efficient referral processes for medical services in Australia, as recommended by the Medicare Benefits Review Committee. The objective was to enhance the provision of timely and appropriate health care by simplifying the referral process. The regulations amend the existing rules for the interpretation of the table of general medical services, introducing three new referral systems: formal letter, informal written communication, and oral request. These changes were designed to accommodate various scenarios, including instances where a written referral is lost or destroyed, and to ensure that urgent services can be rendered without unnecessary delays. The amendments also limit the authorisation period for referrals to a maximum of 12 months, furthering the goal of efficient and timely health care delivery. The regulations came into effect on 7 March 1987, as stipulated in Regulation 2.
Scope and Application
The Health Insurance (Variation of Fees and Medical Services) (No. 46) Regulations, made under the authority of Section 133 of the Health Insurance Act 1973, apply to all medical practitioners, health service providers, and patients who are involved in the provision or receipt of health services that are subject to the Medicare scheme in Australia. These regulations serve to amend the rules for the interpretation of the table of general medical services, which is set out in Schedule 1 to the Act, and which governs the fees for medical services for the calculation of Medicare benefits. The regulations are designed to implement recommendations from the Medicare Benefits Review Committee, which aims to enhance the efficiency and appropriateness of healthcare delivery. They introduce new systems of referral, allowing for formal letters, informal written communications, and oral requests, while also addressing the situation where a written referral has been lost or destroyed and the circumstances under which urgent specialist services may be rendered. Additionally, the regulations limit the period during which a referral may authorise treatment to a maximum of 12 months. The scope of these regulations is national, applying across all states and territories of Australia.
Key Provisions
The Health Insurance (Variation of Fees and Medical Services) (No. 46) Regulations, which amend the existing rules for the table of general medical services under the Health Insurance Act 1973, introduce several new provisions to simplify the process of referring patients to specialist physicians. These changes, which come into operation on 7 March 1987, are in response to recommendations from the Medicare Benefits Review Committee. The regulations allow for three new methods of referral: the preparation of a formal letter of referral, an informal written communication, or an oral request. These methods aim to streamline the referral process and enhance its efficiency.
Under these regulations, the Act’s existing rules for interpretation have been amended to accommodate situations where a written referral has been lost, stolen, or destroyed, and where a service rendered by a consultant physician or specialist is deemed urgent. Furthermore, these rules now limit the period during which a referral authorises treatment to a maximum of 12 months. These amendments seek to provide flexibility and clarity in the referral process, ensuring that it can be conducted efficiently while also safeguarding the quality of patient care.
The Health Insurance (Variation of Fees and Medical Services) (No. 46) Regulations impose certain obligations on medical practitioners, including the requirement to follow the specified methods of referral as outlined in the amended rules. Practitioners must ensure that referrals are appropriately documented and communicated, whether through formal letters, informal written communications, or oral requests. Additionally, the regulations require that services rendered under a referral be justified and necessary, particularly in cases where the referral document has been lost or destroyed, and the urgency of the situation is deemed critical by the specialist.
Failure to comply with these regulations may result in civil or criminal penalties. Although the specific penalties are not detailed in the Explanatory Statement, breaches of the Health Insurance Act 1973 or its regulations can lead to substantial fines and potential legal action. For instance, misleading or fraudulent claims for medicare benefits can result in penalties that include fines of up to $22,200 for individuals and $111,000 for corporations, as per section 132 of the Act. Additionally, more severe breaches may attract criminal charges, leading to imprisonment, depending on the nature and extent of the violation.