4.1.3 The aim of the medical services program is to ensure that as far as practicable entitled persons have access to free, safe and cost‑effective treatment.
To achieve this objective the Commission or the Department deals with medical practitioners on two levels.
At the first level the Commission or the Department deals with medical practitioners called general practitioners. Services provided by these medical practitioners must be in accordance with these Principles and the Notes for General Practitioners if the Department is to pay for the services.
It should be noted that while it is the Commission that accepts financial liability for treatment it is the Department (Commonwealth) that actually pays for the treatment.
The second level of interaction between the Commission or the Department and medical practitioners is where the medical practitioner is a specialist.
Unlike general practitioners, medical specialists (as at 1 April 2006) are not prepared to submit to the same level of regulation as general practitioners regarding services to entitled persons (at DVA expense) but if they are prepared to treat an entitled person at the rate set out in the Principles and charge DVA and not the entitled person, then the relationship between DVA and the specialist is covered by the Principles.
4.1.4 Subject to paragraph 3.5.1, the Commission may accept financial liability for medical treatment provided to an entitled person by a general practitioner or a medical specialist.
Note: paragraph 3.5.1 sets out the financial limits on Commission liability for treatment.
4.2 Providers of services
4.2.1 Unless otherwise indicated in these Principles, an entitled person may be provided with only those services included in the Medicare Benefits Schedule.
4.2.2 The services referred to in paragraph 4.2.1 may be provided only by:
(a) a general practitioner; or
(b) a medical specialist.
4.2.3 (1) An entitled person may be provided with services that are not made available under the Medicare Benefits Schedule or the Department of Veterans’ Affairs Fee Schedules for Medical Services (unlisted services).
(2) Unlisted services are not to be provided to an entitled person if the Commission is satisfied that they are:
(a) a mere improvement on existing Medicare Benefits Schedule listed services; or
(b) experimental and have not been demonstrated to be effective or safe by extensive clinical trials.
4.2.4 Subject to paragraph 4.2.3(2), unlisted services are to be provided to an entitled person under paragraph 4.2.3(1) if the Commission is satisfied that the services will provide a substantial benefit to the health of the entitled person.
Part PART 4 - MRCA Treatment Principles (No. MRCC 53/2013) - MEDICAL PRACTITIONER SERVICES | Zoe
Note 1: the prior approval of the Commission is required before unlisted services may be provided (Paragraph 3.2.1 (b)).
Note 2: the availability of funds and the need to reasonably control expenditure are factors to be considered in granting prior approval (Subparagraphs 3.2.2 (c) and (d)).
4.2.5 The services referred to in paragraph 4.2.3 may be provided only by:
(a) a general practitioner; or
(b) a medical specialist.
4.2.6 Optical Coherence Tomography
4.2.7 The Commission may accept financial responsibility for Optical Coherence Tomography (OCT) provided to an entitled person by an Ophthalmologist for the assessment or management of retinal disease.
Note: While OCT remains an unlisted treatment it is subject to all the requirements for an unlisted treatment except prior approval.
4.2.8 DVA Fee Schedule Services
4.2.9 Despite paragraph 4.2.1, an entitled person may be provided with services included in the Department of Veterans’ Affairs Fee Schedules for Medical Services.
4.2.10 Services provided under paragraph 4.2.9 may be provided only by a general practitioner or a medical specialist.
4.2.11 Prior approval is not required for services provided under paragraph 4.2.9.
4.3 Financial responsibility
4.3.1 Subject to paragraph 3.5.1, and unless otherwise indicated in these Principles, the Commission will accept financial responsibility for treatment costs where a general practitioner or specialist provides or arranges for treatment of:
(a) an entitled person who has been issued with a Gold Card; or
(b) an entitled person who has been issued with a White Card for any service injury or service disease; or
(c) a person who has been issued with a written authorisation on behalf of the Commission;
Note: Principle 3.5.1 also deals with financial liability for medical practitioner fees.
4.3.2 In relation to any occasion of service to an entitled person under these Principles, a general practitioner or specialist shall bill only:
(a) the Department; or
(b) the Commission; or
(c) the Human Services Department,
and that bill shall be for full settlement of the account for the service provided to the entitled person.
4.3.3 Any billing method described in paragraph 4.3.2 may be used on each occasion of service.
4.3.4 Subject to paragraph 4.7.3, the Commission will accept financial responsibility for any of the services described in paragraph 4.4.1, irrespective of the billing arrangement chosen under paragraph 4.3.2 by the referring general practitioner or specialist.
4.3A Disqualified Medical Practitioners
4.3A.1 The Commission is not to accept financial responsibility for the cost of a medical service provided to an entitled person by, or on behalf of, a general practitioner or a medical specialist if, at the time the service was provided, a medicare benefit would not have been payable in respect of the service under section 19B or section 19C of the Health Insurance Act 1973 (in force from time to time) if the general practitioner or medical specialist had provided the service as a practitioner under that Act.
4.4 Referrals
4.4.1 A general practitioner may refer an entitled person for:
(a) treatment from a medical specialist, subject to paragraph 4.7.1, and principles 4.5 to 4.8; or
(b) treatment from a general practitioner who has expertise or recognition in a particular field but is not a qualified medical specialist, subject to principles 4.5 to 4.8; or
(c) treatment in a hospital or other institution as indicated in these Principles; or
(d) other health‑care services not requiring prior approval, as indicated in principles 7.3, 7.5 and 7.6.
4.5 Referrals by medical specialists
4.5.1 In providing treatment, a medical specialist, to whom an entitled person is referred under these Principles, may:
(a) arrange diagnostic tests; or
(b) refer the entitled person to another specialist in the same way as may a general practitioner; or
(c) arrange treatment in a hospital or other institution as indicated in these Principles; or
(d) refer the entitled person to a health‑care provider in accordance with principles 7.3, 7.5 or 7.6, in the same way as may a general practitioner.
4.7 Referrals: prior approval
4.7.1 In all instances other than those described in paragraph 4.7.3 and the MRCA Private Patient Principles 2004, prior approval is required for the referral of entitled persons to medical specialists.
4.7.2 Prior approval is required for:
(a) the provision of psychotherapy treatment to entitled persons; or
(b) the provision of services under paragraph 4.2.3.
4.7.3 Prior approval is not required when a general practitioner or medical specialist refers an entitled person to a medical specialist for diagnostic imaging or pathology services not requiring admission and the medical specialist direct bills the Human Services Department at 100 per cent or less of the fee set out in the Medicare Benefits Schedule as full settlement of the account for the service rendered.
4.8 Other matters
4.8.1 The Commission will not accept financial responsibility for the cost of:
(a) elective surgery undertaken without prior approval with the exception of elective surgery in a public hospital, minor procedures carried out in a general practitioner’s or specialist’s rooms where the only charge is equivalent to the charge that would be applicable under the Medicare Benefits Schedule for that procedure; or
(b) examination for a medical certificate for life assurance purposes; or
(c) examination for a medical certificate for membership of a friendly society; or
(d) examination for employment purposes; or
(e) multi‑phasic screening; or
(f) services where the cost is otherwise recoverable wholly or partly, by way of a legal claim; or
(g) services that have been paid for, wholly or partly, by the Human Services Department, as a medicare benefit, or by a health insurance fund; or
(ga) diabetes educator services under this Part that may be provided under Part 7 (Treatment Generally From Other Health Providers).