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HEALTH INSURANCE REGULATIONS (AMENDMENT) 1996 NO. 234
EXPLANATORY STATEMENTSTATUTORY RULES 1996 No. 234
Issued by authority of the Minister for Health and Family Services
Health Insurance Act 1973
Health Insurance Regulations (Amendment)
The Health Insurance Act 1973 (the Act) provides, in part, for the payment of Medicare benefits for professional services rendered by medical practitioners and for certain professional services rendered by dental practitioners and optometrists.
Section 19(6) of the Act provides that Medicare benefits are not payable unless the person by or on behalf of whom the professional service was rendered, or an employee of that person, records certain prescribed particulars on the account or receipt, or, in the case of claims which are bulk billed, the form of the assignment or agreement for fees in respect of the service.
Regulation 13 of the Health Insurance Regulations prescribes the particulars which need to be recorded on accounts, receipts and bulk billing assignments or agreements for professional services for the purposes of subsection 19(6) of the Act.
Subsection 16B(1) of the Act provides, in part that Medicare benefits are not payable for an R-type diagnostic imaging service rendered by the providing practitioner unless there was a written request for the service by a medical or dental practitioner or a chiropractor, a physiotherapist or a podiatrist. Subsection 23DQ(1) of the Act provides that regulations may specify the information that must be included in a written request under subsection 16B(1).
Regulation 19(1) of the Health Insurance Regulations prescribes the information that must be included in subsection 16B(1) requests by practitioners.
Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.
The Regulations amend the Health Insurance Regulations in accordance with the Government's 1996-97 Budget commitments. The Regulations will assist the Commonwealth to obtain data relating to the use of Medicare funded services in hospital settings in order to facilitate better assessment of funding levels to State and Territory hospitals.
The Regulations require:
* all practitioners providing professional services to identify on their accounts, receipts or assignments of benefit; and
* all practitioners requesting R-type diagnostic imaging services to identify on their written requests
those services which in their opinion are hospital-related services.
Identifying these services will not affect the payment of Medicare benefits.
The Regulations amend Regulation 13 of the Health Insurance Regulations by prescribing additional particulars to be recorded on accounts, receipts and bulk billing assignments or agreements.
Subregulation 13(20) provides that where a practitioner forms an opinion that a professional service is a hospital-related service, within the meaning of subregulation 13(21), the practitioner is to record on the account or receipt the prescribed particular, namely, the letter "A". If it is a bulk billed hospital-related service the practitioner is to record on the assignment or agreement the prescribed particular, namely, the letter "A", except where the practitioner notifies the Health Insurance Commission, by means of an approved form known as a form DB1C, of an assignment or agreement in relation to the Medicare benefit in respect of the service.
Subregulation 13(21) defines a professional service which is a "hospital-related service" as:
(a) a professional service provided in relation to a person for a condition in relation to which the person will, or is likely to, receive treatment in a hospital or day hospital facility within 4 weeks of the service being provided; or
(b) a professional service provided in relation to a person for a condition in relation to which the person had received treatment in a hospital or day hospital facility in the 4 weeks immediately before the service was provided; or
(c) a professional service provided in relation to a person for a condition in relation to which, immediately before receiving the service, the person had presented for treatment to a recognised hospital and was referred or redirected to the practitioner who provided the service; or
(d) a professional service provided at a recognised hospital in relation to a person who is not admitted to that hospital in connection with that service.
Subregulation 13(22) provides that, in reaching an opinion as to whether a professional service is such a hospital-related service, the practitioner must have regard to the nature of the professional service provided to the person concerned, and all the circumstances in which the service was provided, including, but not limited to:
(a) the results of any examination of the person by the practitioner; and
(b) the results of any tests in relation to the person conducted by, or made available to, the practitioner; and
(c) the history, or any other information, given to the practitioner by the person; and
(d) any letter, form or document given to the practitioner in connection with the provision by the practitioner of the service.
The Regulations also amend Regulation 19 of the Health Insurance Regulations by requiring additional information be included in requests for diagnostic imaging services.
Paragraph 19(1)(d) provides that where a requesting practitioner forms an opinion that the requested R-type diagnostic imaging service is a hospital-related service, within the meaning of subregulation 19(1A) the request should be identified by the letter "A".
Subregulation 19(1A) defines an R-type diagnostic type service which is a "hospital-related service" as:
(a) a diagnostic imaging service requested in relation to a person for a condition in relation to which the person will, or is likely to, receive treatment in a hospital or day hospital facility within 4 weeks of the service being provided; or
(b) a diagnostic imaging service requested in relation to a person for a condition in relation to which the person had received treatment in a hospital or day hospital facility in the 4 weeks immediately before the service was provided; or
(c) a diagnostic imaging service requested in relation to a person for a condition in relation to which, immediately before receiving the service, the person had presented for treatment to a recognised hospital and was referred or redirected to the practitioner who provided the service; or
(d) a diagnostic imaging service requested at a recognised hospital in relation to a person who is not admitted to that hospital in connection with that service.
Subregulation 19(1B) sets out the criteria a practitioner should have regard to when reaching an opinion as to whether a diagnostic imaging service is a such a hospital-related service, namely, the nature of the diagnostic imaging service and all the circumstances in which the .service was provided, including, but not limited to:
(a) the results of any examination of the person by the practitioner; and
(b) the results of any tests in relation to the person conducted by, or made available to, the practitioner; and
(c) the history, or any other information, given to the practitioner by the person; and
(d) any letter, form or document given to the practitioner in connection with the provision by the practitioner of the service.
The Regulations will commence on 1 November 1996.