Health Quality and Complaints Ombudsman

Health Quality and Complaints Ombudsman

Phone: 1800 640 695

Fax: (02) 6276 0123

Email:

Dear Ombudsman,

On behalf of Specialist Practice:

I would like to make a complaintabout the actions ofthe private health insurance company/s:

The Ophthalmologist/s in the Practicemake clinical recommendations that patients receive surgical procedures that are medically necessary to correct eyelid abnormalities. These procedures include items 45617, 45623, 45624 and 42590.

The procedures are compliant with the Australian Medicare Benefits Schedule item number descriptions and are claimable through the MBS.

The procedures are covered by patients’ private health insurance policies.

However, the private health insurer is demandingthat Ophthalmologists complete a ‘Specialist Eligibility Form’ before these procedures can be undertaken. The Insurer is often indirectly enforcing doctor compliance with Specialist Eligibility Forms through private surgical facilities and hospitals, advising these facilities/hospitals that they may not receive payment if the form is not signed before the procedure is performed.

The private health insurer then uses this form to assess the Ophthalmologists’ clinical recommendation and determine patient eligibility for receiving cover for the procedures; despite the fact that the patient’s health policy covers them for these procedures.

The Health Provider Compliance Division of the Australian Government Department of Health, has advised the following:

The Private Health Insurance Act 2007 requires private health insurers to pay benefits for hospital treatment when a member undergoes a procedure, which is covered by their complying health insurance product (CHIP) and a Medicare benefit is payable.

This requirement is set out under section 72-1(1)(a) of the Act and states that an insurance policy that covers hospital treatment meets the benefit requirement rules in Division 72 if the policy meets the requirements in the table in subsection (2). The table in section 72-1(2) of the Act states in item 2 that there must be a benefit for hospital treatment covered under the CHIP for which a Medicare benefit is payable.

Therefore pre-approval procedures such as the requirement for Specialist Eligibility Forms are contrary to Private Health Insurance regulation.

Further, pre-approvals are an entirely inappropriate interference with the doctor-patient relationship and contravene the basic principles of patient care.

Health Insurers have no right to make clinical judgmentsin relation to patients’ health needs above the clinical decision made by their Ophthalmologist.

I ask that you take action to stop the requirement for pre-approvals and Specialist Eligibility Forms by the private health insurance company/s:

Sincerely,

NAME:

PHONE NUMBER:

EMAIL ADDRESS:

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