Commonwealth Numbered Regulations - Explanatory Statements

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HEALTH INSURANCE REGULATIONS (AMENDMENT) 1991 NO. 82

STATUTORY RULES 1991 No. 82

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 certain professional services rendered by dental practitioners and optometrists.

Section 133 of the Act provides that the Governor-General may make regulations for the purposes of the Act.

The Community Services and Health Legislation Amendment Act (No. 2) 1990, which received Royal Assent on 28 December 1990, amended the Act by introducing new provisions governing the payment of Medicare benefits for diagnostic imaging services (i.e. diagnostic radiology, computerised tomographic scanning, ultrasound, magnetic resonance imaging and nuclear scanning).

The diagnostic imaging provisions of the Act provide that, except in certain circumstances, Medicare benefits are only payable for a diagnostic imaging service if it is rendered by a medical practitioner pursuant to a written request from another practitioner who has no financial interest in the rendering of that service. The services which are subject to the written request requirement are classified as "Rtype" services. Practitioners entitled to request "R-type" imaging services are medical practitioners, dental practitioners and chiropractors, although the last two may only request certain services.

Services not subject to the written request requirement are classified as "NR-type" services. The services in this category are those which have historically been recognised as falling within the competence of general practitioners. They include X-rays of the extremities, shoulder, chest and abdomen.

The diagnostic imaging provisions of the Act provide for the making of regulations in respect of the following:

(1)       the creation of a new diagnostic imaging services table [subsection 4AA of the Act];

(2)       the specification of a restricted number of diagnostic imaging services which, may be requested by dental practitioners and chiropractors [subsections 16B(2) and 16B(3) of the Act];

(3)       the specification of diagnostic imaging services which may be exempted from the written request ("arm's length" referral) requirement under the pre-existing diagnostic imaging practices ("grandparent") provision [subsection 16B(11) of the Act];

(4)       the form in which requests for diagnostic imaging services must be made and the information that must be included in such requests [subsection 23DQ(1) of the Act]; and

(5)       the form in which records of diagnostic imaging services are to be prepared, the information that must be included therein, and the manner in which the records must be kept [subsection 23DS(1) of the Act].

The creation of the diagnostic imaging services table, which is covered by the Health Insurance (1991 Diagnostic Imaging Services Table) Regulations, brings together the items of diagnostic imaging service previously listed in the general medical services table.

The Health Insurance Regulations (Amendment) amends the Health Insurance Regulations to provide for those matters listed in (2) to (5) above.

Regulations 1 and 2 are commencement and introductory provisions. Regulation 3 provides for the allocation of requester numbers to chiropractors.

The Regulations provide in regulation 4 that the "R-type" imaging services which may be requested by dental practitioners are restricted to X-rays of the head and that those that may be requested by chiropractors are restricted to X-rays of the spinal region . These restrictions were announced in Parliament at the time the diagnostic imaging legislation was introduced.

Regulation 4 also specifies the items of diagnostic imaging service which are exempted from the general "arm's length" request/referral requirement under the "grandparent" provision of the Act. The list of "Rtype" items exempted under this provision was compiled in consultation with the Royal Australian College of General Practitioners, the Australian Medical Association and the Royal Australasian College of Radiologists. The services covered by the specified items include X-rays of the spine, pelvic region, skull and facial bones, ribs, kidneys and gallbladder.

The "grandparent" exemption allows the continued payment of benefits for the services specified in proposed Regulation 4 when they have been rendered by general practitioners who have provided, between 18 October 1988 and 17 October 1990, at least 50 services of the kind that will be subject to the referral requirement from 1 May 1991. The "grandparent" exemption expires on 1 January 1993.

The amendments in Regulation 5 dealing with the prescribed particulars to be included on accounts or receipts, or on Medicare assignment forms (for the purposes of subsection 19(6) of the Act), are consequential ones necessitated by the proposed creation of a new diagnostic imaging services table.

Regulation 5 requires that the name and provider number, or the name and address, of the requesting practitioner, and the date of request be entered on the providing practitioner's account or receipt, or on the Medicare assignment of benefits form, along with the normal particulars of the patient, the services provided and the fees charged.

The Regulations also require, in Regulation 6, that these particulars must be included in written requests for "R-type" services. The above request details are needed to satisfy the Health Insurance Commission that the services have been provided in accordance with the requirements governing the payment of Medicare benefits.

Regulation 6 further provides that the records of diagnostic imaging services must be retained by medical practitioners in a manner that facilitates retrieval on the basis of the patient's name and date of service. It requires that the records must include the report by the providing practitioner on the diagnostic imaging service, and where services are rendered in emergency circumstances or under a request that is lost and later confirmed to have been made, that the records show this fact.