EXPLANATORY STATEMENT
Veterans’ Entitlements (Treatment Principles – Removal of Prior Approval Requirement for Optical Coherence Tomography) Instrument 2011
EMPOWERING PROVISION
Section 90 of the Veterans’ Entitlements Act 1986 (the Act).
PURPOSE
The attached instrument (R19/2011) amends the Treatment Principles. The Treatment Principles (the Principles) is a legislative instrument made under section 90 of the Act and sets out the circumstances in which the Repatriation Commission (Commission) may accept financial responsibility for treatment provided to veterans or their dependants (entitled persons).
The purpose of the attached instrument is to remove the requirement in the Principles for health care providers to obtain the approval of the Repatriation Commission (in practice - the Commission’s delegate) before Optical Coherence Tomography (OCT) can be provided to the entitled person (prior approval requirement).
OCT is a medical procedure used for diagnosis and monitoring of retinal diseases in a specialist ophthalmologic setting.
Prior approval was required for OCT because it is an “un-listed treatment” under the Principles. This means it is not listed on the Medicare Benefits Schedule (MBS).
The attached instrument does not alter the status of OCT as an un-listed treatment, meaning that the rules in the Principles in relation to un-listed treatments apply to OCT except the rule that requires the Repatriation Commission’s prior approval before an un-listed treatment may be provided.
In any event although OCT is an un-listed treatment the Medical Services Advisory Council found it to be safe. Nevertheless at the time the attached instrument commenced the procedure was not listed on the MBS.
The problems with the prior approval requirement for OCT were that it was difficult in practice for health care providers to comply with the requirement because OCT is usually provided during a consultation and the short time frame between determining a need for the procedure and providing it did not normally enable prior approval to be obtained.
Further, because it was impractical to obtain prior approval, health care providers needed to obtain retrospective approval. But the rules governing retrospective approval were more stringent than those applying to prior approval.
In any event, the Department of Veterans’ Affairs (DVA) found that the requirement for health care providers to obtain approval for OCT, whether before providing the service or after, was unnecessary and therefore an administrative burden on both health care providers (need to request approval) and DVA (need to process requests for approval) and accordingly the requirement was removed by the attached instrument.
RETROSPECTIVE
Yes. The instrument is taken to have commenced on 1 May 2011 but for the purposes of subsection 12(2) of the Legislative Instruments Act 2003 it does not negatively affect any person. The instrument is benevolent in nature.
CONSULTATION
Yes – Medicare Australia in respect of processing claims for payment for OCT. Consultation was carried out via meetings, telephone communication and e-mail.
DOCUMENTS INCORPORATED-BY-REFERENCE
No.
FURTHER EXPLANATION
Attachment A.
Attachment A
Items Explanation
[1] sets out the name of the instrument.
[2] provides that the instrument is taken to have commenced on 1 May 2011.
Schedule
1. is a definition section.
2. amends 3.2.1(b) of the Principles (which covers un-listed treatments and is in the part of the Principles that sets out the treatments for which the Repatriation Commission’s prior approval is required) to make it clear that despite the general requirement that un-listed treatments need prior approval, the Principles may specify that prior-approval for a particular unlisted treatment is not necessary.
3. inserts new provisions in the Principles (4.2.6 and 4.2.7). These provisions identify OCT as a medical treatment and provide that the Repatriation Commission may accept financial responsibility for OCT where it is provided to an entitled person by an Ophthalmologist for the assessment or management of retinal disease.
The new provisions also provide that while OCT remains an unlisted treatment it is subject to all the requirements for an unlisted treatment except the requirement that prior approval be obtained before OCT is provided.
Overview
The Veterans’ Entitlements (Treatment Principles – Removal of Prior Approval Requirement for Optical Coherence Tomography) Instrument 2011 was enacted to address the administrative burden and practical difficulties associated with the prior approval requirement for Optical Coherence Tomography (OCT) under the Veterans’ Entitlements Act 1986. This legislative instrument, made under section 90 of the Act, was designed to streamline the provision of OCT, a diagnostic and monitoring tool for retinal diseases, by removing the need for health care providers to seek prior approval from the Repatriation Commission before administering the treatment to entitled persons. Despite OCT being classified as an un-listed treatment and not appearing on the Medicare Benefits Schedule, the instrument maintains that OCT is subject to all other requirements for un-listed treatments, except for the necessity of prior approval, in alignment with findings by the Medical Services Advisory Council on its safety.
The instrument was introduced following consultations with Medicare Australia to ensure its implementation would not negatively affect any person, reflecting a benevolent approach as per the Legislative Instruments Act 2003. It took effect from 1 May 2011, aiming to alleviate the administrative load on both health care providers and the Department of Veterans’ Affairs by simplifying the approval process for OCT, thereby enhancing the efficiency of treatment provision for veterans and their dependants.
Scope and Application
The Veterans' Entitlements (Treatment Principles – Removal of Prior Approval Requirement for Optical Coherence Tomography) Instrument 2011 applies to health care providers who provide Optical Coherence Tomography (OCT) services to veterans or their dependants, who are entitled persons under the Veterans' Entitlements Act 1986. The instrument removes the prior approval requirement for OCT, which was previously considered an un-listed treatment and necessitated prior approval from the Repatriation Commission. Despite this removal, OCT continues to be classified as an un-listed treatment, subject to all other rules applicable to un-listed treatments except for the prior approval requirement. This legislative instrument operates within the Commonwealth jurisdiction and is designed to alleviate the administrative burden experienced by both health care providers and the Department of Veterans’ Affairs. The instrument is retrospective, effective from 1 May 2011, and is benevolent in nature, meaning it does not negatively affect any person. Consultation with Medicare Australia regarding the processing of claims for OCT payment was conducted through meetings, telephone communication, and email. The instrument does not incorporate any documents by reference.
Key Provisions
The Veterans’ Entitlements (Treatment Principles – Removal of Prior Approval Requirement for Optical Coherence Tomography) Instrument 2011 introduces significant amendments to the Treatment Principles under the Veterans’ Entitlements Act 1986. Specifically, it modifies the provisions concerning Optical Coherence Tomography (OCT) by removing the prior approval requirement for this treatment. Under section 3.2.1(b) of the Treatment Principles, OCT was previously categorised as an "un-listed treatment," which necessitated prior approval from the Repatriation Commission before it could be provided to entitled persons. However, the instrument amends this by specifying that prior approval is not necessary for OCT, while still maintaining that OCT remains subject to all other requirements applicable to unlisted treatments (Schedule 1, item 2).
The Act imposes certain obligations on both health care providers and the Repatriation Commission. Health care providers are now free to provide OCT to entitled persons without first seeking prior approval, provided that the treatment is performed by an Ophthalmologist for the assessment or management of retinal disease. The Repatriation Commission, on the other hand, is obligated to accept financial responsibility for OCT under these conditions, as outlined in the new provisions 4.2.6 and 4.2.7. These provisions ensure that OCT is recognised as a valid treatment for retinal disease, thereby facilitating its use in the appropriate clinical context.
There are no specific offences, penalties, or civil/criminal consequences outlined in the instrument for breaches of the amended Treatment Principles regarding OCT. However, any non-compliance with the conditions for OCT treatment, such as providing it outside the specified clinical context or by non-Ophthalmologists, may still result in the Repatriation Commission refusing to accept financial responsibility for the treatment. This could potentially lead to disputes or claims being denied, but the instrument itself does not introduce new penalties or sanctions beyond the scope of the existing Treatment Principles. The benevolent nature of the instrument, as noted, ensures that it does not negatively affect any person, maintaining its focus on easing administrative burdens and improving access to necessary medical treatments for entitled persons.