General Manager
Private Surgical Facility/Private Hospital
Re: Private Health Insurer pre-approvals are unnecessary
I highly value the benefits to health outcomes my patients’ receive from undergoing my treatment at your private surgical facility/hospital. However, a recent requirement by some private health insurers to obtain pre-approval for my patients’ ophthalmic surgical procedures at your facility/hospital is of great concern.
Pre-approvals are being sought by private health insurers through Specialist Eligibility Forms (SEFs) issued for doctor completion to private facilities/hospitals. SEFs are being required for ophthalmic surgical procedures, item numbers 45617, 45623, 45624 and 42590. However these items are claimable through the MBS and therefore medically necessary and automatically not cosmetic leaving the SEF redundant.
Private health insurers have been disingenuous about their actions to interfere with clinical decision-making. The Chief Medical Officer to Medibank Private advised Ophthalmology Fellows at a recent RANZCO scientific conference that it was not Medibank who required pre-approvals. In further correspondence the CMO claimed that Medibank implemented SEFs in response to private hospital concerns and therefore as a method to assure the private hospitals/facilities that Medibank will pay claims.
The Australian Society of Ophthalmologists (ASO) has condemned the actions of private health insurers in formulating this policy. The ASO maintains that health insurers have no right to make clinical judgments in relation to patients’ health needs above the clinical decision made by their Ophthalmologist.
The Health Provider Compliance Division of the Australian Government Department of Health, has provided the following advice to the Australian Society of Ophthalmologists:
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.
The former Minister for Health the Hon Peter Dutton MP provided the following response to the AMA in relation to the issue:
“The Government believes that the determination of a clinical treatment regime and the assigning of the relevant Medicare benefits Schedule item number should be the exclusive purview of the treating doctor.
It does seem likely that a pre-surgery approval process conducted by a health insurer in the way outlined would contravene the Private Health Insurance Act 2007.”
Therefore pre-approval procedures such as the requirement for Specialist Eligibility Forms are against 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.
The ASO has highlighted this matter with the current Federal Government review of the Private Health Insurance System, and requested Health Minister Sussan Ley address the issue with private health insurers directly.
Therefore I will not be signing Specialist Eligibility Forms and I ask for your support that this will not interfere with my patients receiving treatment at your private facility/hospital.
I have also forwarded my concerns in relation to the actions of private health insurers to the Private Health Insurance Ombudsman.
Sincerely,
Dr
Date:
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