EXPLANATORY STATEMENT
STATUTORY RULES 1987 No 309
ISSUED BY AUTHORITY OF THE MINISTER FOR COMMUNITY SERVICES AND HEALTH
HEALTH INSURANCE ACT 1973
HEALTH INSURANCE (VARIATION OF FEES AND MEDICAL SERVICES) (No 48) 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 in effect that medicare benefits shall be calculated by reference to the fees for medical services set out in the table. The table is defined to mean the table consisting of the general medical services table and the pathology services table. The general medical services table is set out in Schedule 1 to the Act and 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 among other things that the table of general medical services may be varied or replaced by regulations. The Health Insurance (Variation of Fees and
Medical Services) (No 47) Regulations (Statutory Rules 1987 No 160) prescribe the present table of general medical services pursuant to section 4 of the Act.
In that table, there are two sets of associated items: items 110, 116 and 118 and items 122, 128 and 130. The items provide for a professional attendance by a consultant physician in the practice of the physician’s specialty (not being psychiatry) where the patient is referred by a medical practitioner, and where the attendance takes place at one of the locations specified in each of the items. The items are linked sequentially, so that -
• the first item (item 110 or 122) provides for the initial attendance in a single course of treatment;
• the second item (item 116 or 128) provides, at a lesser fee, for the second or third attendance in a single course of treatment; and
• the third item (item 118 or 130) provides, at a lesser fee again, for the fourth or subsequent attendance in a single course of treatment.
This sequential linking does not permit a distinction to be made between attendances of a complex nature and attendances requiring less involvement on the part of the consultant physician.
The Minister for Community Services and Health has agreed to rectify this anomaly. The Health Insurance (Variation of Fees and Medical Services) (No 48) Regulations give effect to the Minister’s decision by omitting items 116, 118, 128 and 130 and inserting new items 116, 119, 128 and 131.
The new items still provide for a professional attendance by a consultant physician in the practice of the physician’s specialty (not being psychiatry) where the patient is referred by a medical practitioner, and where the attendance takes place at one of the locations specified in each of the items. The new items then distinguish between an attendance of a minor nature and an attendance which is not of a minor nature.
The regulations also insert a new rule of interpretation to define an attendance of a minor nature as a second or subsequent attendance in a single course of treatment at which it is not necessary to carry out a physical examination of the patient, and which does not result in any substantial alteration to the treatment of the patient.
The regulations have been prepared in consultation with the Australian Association of Consultant Physicians.
Overview
The Health Insurance (Variation of Fees and Medical Services) (No 48) Regulations 1987 were enacted to amend the fees and services associated with general medical services under the Health Insurance Act 1973. The issue addressed by these regulations was the inadequacy of the existing sequential linking of certain medical service items, which did not permit a distinction between complex and less complex attendances by consultant physicians. This anomaly was rectified by the insertion of new items that distinguish between minor and non-minor attendances, thereby ensuring a more accurate reflection of the level of service provided. The regulations were issued under the authority of the Minister for Community Services and Health and were developed in consultation with the Australian Association of Consultant Physicians, with the policy objective of improving the fairness and accuracy of medical service fee calculations.
Scope and Application
The Health Insurance (Variation of Fees and Medical Services) (No 48) Regulations, issued under the Health Insurance Act 1973, specifically target the table of general medical services and associated fees for medical practitioners, particularly consultant physicians. These regulations apply to medical practitioners who are registered under the Act and are involved in providing services covered by the table, including those who refer patients to consultant physicians for treatment in their specialty, excluding psychiatry. The regulations have a national reach, applying across all states and territories of Australia. They are designed to refine the fee structure for medical services by distinguishing between minor and non-minor attendances, thereby addressing an anomaly in the existing fee structure. The Act allows for the variation of these fees and services through regulations, and these specific regulations were made to ensure clarity and fairness in the classification and remuneration of consultant physician services. Any exclusions or exemptions are not explicitly stated but would be aligned with the existing framework of the Health Insurance Act 1973.
Key Provisions
The Health Insurance (Variation of Fees and Medical Services) (No 48) Regulations (2004) make specific amendments to the table of general medical services under the Health Insurance Act 1973 (the Act). These changes are intended to address certain anomalies in the existing fee structure for medical services provided by consultant physicians. The Act, particularly Section 4, allows for the table of general medical services to be varied or replaced by regulations, which is how these changes are implemented. The existing regulations, Health Insurance (Variation of Fees and Medical Services) (No 47) Regulations, set out the current table of general medical services.
The new regulations, which come into effect under Section 133 of the Act, involve the omission of certain items (116, 118, 128, and 130) and the insertion of new items (116, 119, 128, and 131). These changes aim to better distinguish between different types of medical attendances by consultant physicians, specifically differentiating between minor and non-minor attendances. Previously, items 110, 116, and 118, and items 122, 128, and 130, were sequentially linked but did not differentiate between complex and less complex attendances. The new items still cover professional attendances by consultant physicians but now include a definition for an attendance of a minor nature. This is defined as a second or subsequent attendance in a single course of treatment where no physical examination is necessary and there is no substantial alteration to the patient’s treatment.
Under these regulations, parties governed by the Act, including consultant physicians, medical practitioners, and patients, are required to adhere to the new fee structures as outlined in the updated table of general medical services. Consultant physicians must now ensure that the nature of their attendance is accurately classified as either minor or non-minor, as defined in the new interpretation rule. Medical practitioners must be aware of these changes when referring patients to consultant physicians, and patients should be informed about the potential changes in fees based on the nature of the attendance.
Failure to comply with these regulations could result in legal consequences, although the Act itself does not specify penalties for non-compliance in this context. However, any misrepresentation or incorrect billing practices could potentially lead to investigations or actions under other relevant laws pertaining to healthcare billing and fraud. The regulations were developed in consultation with the Australian Association of Consultant Physicians to ensure that the changes are practical and reflect current medical practices.