GA 2020/0924
Answer
No.
Context
Question: If a clinic receives a referral to “Dear specialist” can this be used by anyone in that practice? Or if it comes to a named specialist, can that validly be used by another provider in the same practice? These are privately referred non-inpatient in a public oncology setting that is bulk billed.
Relevant Legislative Provisions
Health Insurance Regulations 2018
Other Relevant Materials
The National Health Reform Agreement (NHRA)
Published academic journal article that provides some analysis of the challenges reconciling referral law under the Health Insurance Act and the National Health Reform Agreement: Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.
Please read this answer in conjunction with RM 2020/067
Case law
N/A
Departmental Interpretation
servicesaustralia.gov.au (accessed 26 June 2020)
“Referrals for specialist treatment
Patients can be referred to a specialist or consultant physician for treatment of their condition. The referral must include:
- relevant clinical information about the patient’s condition for investigation, opinion, treatment and/or management
- the date of the referral, and
- the signature of the referring practitioner
Referrals don’t need to be made out to a certain specialist or consultant physician.
Referrers should let patients choose where to present the referral, this also applies to electronic referrals.”
Detailed Reasoning
Business Rule G19(b) of the NHRA states that for an outpatient referral to be valid, it must be to: ‘a named medical specialist who is exercising a right of private practice…’ directly contradicting the departments’ interpretation of the Health Insurance Regulations (copied above) which states that a referral does not need to be named.
However, the NHRA overrides the operation of the Health Insurance Regulations to the extent of this inconsistency.
Therefore any referral made out to ‘Dear Specialist’ or ‘Dear Gastroenterologist’ or ‘Dear Fracture Clinic’ or any similar variation where an actual name of a specialist is not present, prevents bulk billing in public hospital outpatient clinics.
NB: Crossing out words, circling a name, changing or amending a referral in any way may constitute fraud.
Examples and other relevant information
If the referral does have a name, but that specialist is not available to see the patient, another specialist of the same specialty can take over the referral in accordance with the reasons provided in RM 2020/067
Who this applies to
All specialists exercising rights of private practice in public hospital outpatient departments.
When this applies
Since August 2011 when significant reforms to public hospital funding were introduced