Medibank s Requirements for Recognised Providers

Transcription

1 Medibank s Requirements fr Recgnised Prviders Intrductin Medibank Private Limited (Medibank) ffers private health insurance prducts under tw different brands, Medibank Private and ahm Health Insurance. Medibank is an industry leader with a fcus n ensuring ur members get quality healthcare utcmes within a system which remains affrdable fr all f the cmmunity. We recgnise the valuable services delivered by ancillary prviders t ur mre than 3.8 millin members acrss the ahm and Medibank brands. T becme a recgnised prvider with Medibank yu must apply fr recgnitin (in accrdance with such requirements as apply t the prvider s mdality and available n Medibank s website) and meet the requirements set ut in this dcument. A recgnised prvider is a health prvider recgnised by Medibank fr the purpse f paying benefits n behalf f its members in relatin t treatment prvided. All treatments must be in accrdance with Medibank s Fund Rules and the requirements set ut in this dcument. T avid dubt, benefits are nt payable in relatin t treatment prvided where the member is ineligible fr benefits in respect f that treatment under their private health insurance plicy. At Medibank s abslute discretin, Medibank may refuse t grant recgnitin r suspend r cancel a Recgnised Prvider s recgnitin with immediate effect r with ntice depending n the circumstances. Medibank s Requirements Ancillary prviders must cmply with the fllwing requirements t becme, and t cntinue t be recgnised as, a Medibank Recgnised Prvider. 1. Independent private practice Services and gds prvided t Medibank s members must be prvided in independent private practice ; that is, a prfessinal practice (whether sle, partnership r grup) that is selfsupprting. This means that its accmmdatin, facilities and services are nt prvided r subsidised by anther party (such as a public hspital r publicly funded facility). 2. Prfessinally qualified a. Prviders cvered under the Natinal Registratin and Accreditatin Scheme 1 These prviders must: Be registered, r hld a licence, under any relevant Australian state r territry legislatin; Meet all f the standards, including applicable cdes f cnduct, set ut by Australian Health Practitiner Regulatin Agency (AHPRA), the assciated Natinal Bards, the Private Health Insurance (Accreditatin) Rules and Regulatins, and any ther applicable peak bdy that gverns and/r regulates a particular prvider s standards; 1 The Natinal Registratin and Accreditatin Scheme as regulated by the Australian Health Practitiner Regulatin Agency. Page 1 f 7

2 3. Facilities Ntify Medibank within 10 business days if AHPRA r any ther applicable regulatry r accreditatin bdy ceases, suspends, r places cnditins r restrictins n the prvider s registratin. b. Prviders nt cvered under the Natinal Registratin and Accreditatin Scheme These prviders must: Be prfessinally qualified and/r a member f a prfessinal bdy recgnised by Medibank (except fr ptical dispensers); Meet all f the standards set ut by the Private Health Insurance (Accreditatin) Rules and Regulatins and any applicable peak bdy that gverns and/r regulates the prfessinal standards applicable t a particular prvider; Ntify Medibank within 10 business days if the prvider is charged with an indictable ffence r the prvider s prfessinal assciatin ceases, suspends r places cnditins r restrictins n the prvider s qualificatin and/r membership. 4. Service integrity Have facilities that, in Medibank s pinin, meet the standards expected f a prfessinal service prvider; Practice frm and cnsult with patients at prfessinal, clinically apprpriate facilities which, t avid dubt, excludes facilities incrprated int a retail business setting 2 (this excludes the dispensing f ptical gds and hearing aids); Cmply with any Australian state and territry laws relating t facilities in which the treatment is prvided and, where applicable, have permissin r apprval t supply a treatment f that kind, in which case the facilities must have that permissin r apprval; Nt perate in a setting that, in the pinin f Medibank, is a business mdel that may result in a cnflict f interest. This includes, but is nt limited t, a setting that creates the inference f a financial, prfessinal r persnal interest r relatinship between the prvider and a third party that may, in Medibank s pinin, impact n the treatment r prvisin f gds r services t the patient. Make available t Medibank r its authrised representatives, n request and within 10 business days, patient recrds relating t Medibank s members fr the purpse (and related purpses) f validating services prvided t Medibank s members by the prvider. 2 A retail business setting is defined as a lcatin where the primary business purpse, in the pinin f Medibank, is the prvisin f gds r services that are nn-clinical in nature. Page 2 f 7

3 Where the patient recrds are nt in the pssessin f the Recgnised Prvider, the Recgnised Prvider cnsents t the hlder(s) f the patient recrds making the recrds available t Medibank r its authrised representatives fr the abve purpses. This requirement and cnsent shall survive ntwithstanding the Recgnised Prvider s ceasing t practice at a particular lcatin r the suspensin r cancellatin f a Recgnised Prvider s recgnitin; Ntify Medibank within 10 business days if the prvider is n lnger in independent private practice; Cmmunicate with Medibank in English; Nt discriminate against a Medibank member (fr example, by treating them differently t ther patients) n the basis f the member hlding private health insurance, r a particular level f cver. This includes impsing a financial charge r ffering an inducement in respect f the prvider s services that wuld nt be impsed r ffered if private health insurance, r a particular level f cver, was nt held. 5. Patient recrds Maintain cmprehensive and accurate patient recrds that cmply with applicable laws and prfessinal standards, including, but nt limited t, privacy and health recrds management legislatin (including the Cmmnwealth Privacy Act 1988) and industry cdes and standards relating t cllecting, using and disclsing persnal and sensitive infrmatin; 3 Ensure that patient recrds fr Medibank s members: identify the service prvider; are in chrnlgical rder and made at the time f prviding the service r as sn as practicable afterwards; clearly identify the patient and the treatment prvided including, but nt limited t, relevant medical histry, presenting cmplaint, details f previus treatments and referrals; are a detailed, true and accurate reflectin f all treatments/services/gds prvided; are stred in a manner that allws fr prmpt retrieval are written in English; are in a frmat that is understandable by a third party and allws fr cntinuity f care; and in the case f Natural Therapies, identify technique used, bdy parts treated and methds applied, in additin t specific details f gds supplied, including dsage; Where nt therwise specified under applicable laws r prfessinal standards, retain patient recrds fr a minimum f 7 years frm the date the relevant service is prvided t a Medibank member. 3 As defined under the Privacy Act 1988 (Cth). Page 3 f 7

4 6. Billing integrity Cmply with the terms and cnditins f electrnic claiming facilities including, but nt limited t, HICAPS and CSC HealthPint, where a prvider elects t use such electrnic claiming facilities; Obtain the infrmed financial cnsent f Medibank s members prir t the cmmencement f any treatment r the prvisin f any gds; Immediately stp using electrnic claiming, r any ther claiming channel, t prcess health insurance claims in respect f Medibank s members at Medibank s request; Where the prvider elects nt t use electrnic claiming facilities, prvide a valid invice t a Medibank member fr services prvided; Have and use a current prvider registratin number fr each lcatin where the prvider engages in private practice and bill Medibank members fr services at that lcatin. All accunts, receipts and ther supprting dcumentatin shuld clearly reflect the physical lcatin where the service r gds were prvided; Nt allw (whether knwingly r therwise) anther persn t bill services t Medibank s members under their prvider registratin number when the services were nt prvided by the prvider (except fr ptical dispensers, dental hygienists, dental therapists and ral health specialists); Immediately ntify Medibank f any suspected misuse r abuse f their prvider registratin number; Prvide all billing related infrmatin t Medibank s members custmers in English; Issue receipts in sequential rder with individual invice/receipt number Prvide Medibank s members with a separate receipt and/r invice fr each date f service that is issued n the prvider s fficial statinery r bears the prvider s fficial stamp r is therwise identifiable as an riginal dcument and: itemises in full all treatments prvided n the relevant date f service; clearly states the date f payment and the payment status; details the patient s name, address and ther relevant identifying details; and is signed by the service prvider r their authrised representative (if the receipt is signed by an authrised representative the representative s name shuld als be listed and legible); When treating a family member and/r business partner, ensure billing is strictly in accrdance with Medibank s Fund Rules. Page 4 f 7

5 7. Prvider persnal infrmatin By prviding services t Medibank s members a prvider: Cnsents t Medibank cllecting their persnal infrmatin 4 in rder t register them as a Recgnised Prvider and t enable claims t be assessed fr payment frm Medibank fllwing treatment f a Medibank member; Cnsents t the use and disclsure f their persnal infrmatin in rder t: prcess their applicatin and manage their registratin; manage Medibank s relatinship with them; prmte their status as a Recgnised Prvider t Medibank s members, including n Medibank s website; prmte the lcatin f their practice and their mdalities t Medibank s members; prcess and audit payments and claims; detect, analyse, investigate, pursue r prevent suspected fraudulent and/r abusive practices; manage and reslve any legal r cmmercial cmplaints r issues; perfrm ther functins and activities relating t Medibank s business; and cmply with Medibank s legal bligatins. Cncerns r queries abut the manner in which persnal infrmatin is handled can be directed t Medibank s Privacy Officer by writing t privacy@medibank.cm.au. Failing t satisfy Medibank s Requirements If, in Medibank s pinin, a Recgnised Prvider fails t satisfy these Requirements r any ther cncern that Medibank reasnably identifies, Medibank may: Give the prvider 10 business days ntice t respnd t Medibank s cncerns abut their cnduct r practices; Seek t have the prvider explain their cnduct (including in writing); Seek t meet with the prvider t respnd t cncerns identified by Medibank; Seek restitutin fr the services billed t Medibank s members where fraudulent, imprper r errneus billing has ccurred and/r where services d nt meet the requirements f AHPRA, Natinal Bards r any ther applicable peak bdy that gverns r regulates a particular prvider s standards, r Medibank s Fund Rules; Reprt the matter t the relevant prfessinal assciatin r regulatry r law enfrcement agency, including, but nt limited t, AHPRA, the Health Care Cmplaints Cmmissin and the relevant Natinal Bard r ther bdy; Suspend r cease recgnitin f a Recgnised Prvider while an investigatin by Medibank r by an authrised third party is underway; r Suspend r n lnger recgnise any r all prviders perating at a particular lcatin if, in Medibank s pinin, the lcatin is identified as being assciated with suspected fraud r imprper cnduct. 4 As defined under the Privacy Act 1988 (Cth). Page 5 f 7

6 Suspensin r cancellatin f Recgnised Prvider status Medibank reserves the right t suspend r cancel a Recgnised Prvider s recgnitin if it cnsiders it reasnable. This may be where a Recgnised Prvider fails t satisfy these Requirements r in circumstances where Medibank cnsiders that suspensin r cancellatin f recgnitin is reasnable. Examples f circumstances in which Medibank may suspend r cancel a Recgnised Prvider s recgnitin include, but are nt limited t: Medibank cnsiders that the prvider has exceeded a reasnable utilisatin level taking int accunt the average services prvided. Reasnable utilisatin level refers t the average services prvided t Medibank members cmpared t peers in the same mdality with similar demgraphic criteria as determined by Medibank; Medibank cnsiders that the prvider has exceeded a fair and reasnable charge fr treatment r gds prvided. Fair and reasnable charge refers t the average charge billed by the prvider t ther Medibank members and/r cmpared t average billing f peers in the same mdality with similar demgraphic criteria as determined by Medibank; A prvider is fund t be in breach f any law r is cnvicted f a crime; Medibank cnsiders that a prvider has brught int disrepute, r has ptentially brught int disrepute, the Medibank brand, its reputatin within the cmmunity r its prfessinalism; Medibank cnsiders that a prvider s style f advertising r prmtin infers that treatment, gds r services ffered by the prvider are nn-clinical in nature; Medibank makes a business decisin t n lnger recgnise prviders f a certain type; A prvider fails t prperly handle persnal infrmatin, including financial infrmatin, f patients, in breach f relevant privacy laws; The prvider s cnduct des nt meet the duty f care, skill and diligence apprpriate t the treatment that a prvider f that class shuld have prvided; In Medibank s pinin, the prvider refuses t make available upn reasnable request (where reasnable ntice is given) infrmatin requested by Medibank which is relevant t a member s receipt f treatment frm a prvider; A prvider is n lnger recgnised by r has been remved frm a prfessinal assciatin f which the prvider shuld be a member (including being remved because f a breach f the prfessinal assciatin s articles f assciatin r required standards f cnduct); In Medibank s pinin, the prvider has breached the cde f cnduct f AHPRA r their prfessinal assciatin; The prvider has used Medibank trademarks withut the express permissin f Medibank, r cntinues t d s in circumstances where they have been asked t stp; The prvider has failed t take steps, as required by Medibank, t remedy a failure t satisfy these Requirements, r applicable supplementary cnditins, r is unable t rectify that failure t Medibank s satisfactin; Page 6 f 7

7 The prvider has acted imprperly, in Medibank s pinin, and has adversely affected the interests f any f Medibank s members; The prvider has, in Medibank s pinin, thrugh unacceptable cnduct, adversely affected Medibank s financial interests, e.g. prviding a Medibank member with a false and/r misleading accunt/receipt; The prvider s unique prvider registratin number is used by anther persn t bill services nt prvided by the Recgnised Prvider (except fr dental hygienists, dental therapists and ral health specialists); Medibank, in its abslute discretin, chses t n lnger recgnise a particular prvider. Other matters These Requirements are available n Medibank s website and were last updated n 24 March These Requirements may be amended by Medibank frm time t time. All Recgnised Prviders are encuraged t regularly visit Medibank s website t keep up t date with the mst recent updates t these Requirements. Medibank may, frm time t time, issue supplementary cnditins as it cnsiders reasnable, including t address specific issues relevant t particular prvider grups. Where Medibank des s, Medibank will make all relevant dcuments available n its website. Page 7 f 7