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News Bulletin : ADA News Bulletin December 2011
25 DECEMBER 20 11 Therefore, items 56025 and 56026 require a report from a radiologist. Item 56026 (NK) refers to diagnostic scanning performed with older machines which are at least 10 years old. In summary it is important that you: • use the correct Medicare item numbers; • do not claim multiple item numbers for what is essentially the same service; and • you have appropriate contracts in place with the correctly- qualified and registered healthcare professionals to provide, supervise and write the reports. The Medical Services Advisory Committee (MSAC) is currently investigating submissions in relation to final item number for CBCT technology, with the second Protocol Advisory Subcommittee expected to report in March 2012. REQUEST REQUIREMENTS The Medicare Benefits Schedule (MBS) states, amongst other matters, that Medicare benefits are not payable for diagnostic imaging services that are classified as R-type (requested) services unless prior to commencing the relevant service, the practitioner receives a signed and dated request from a requesting practitioner who determined the service was necessary. WHO MAY PROVIDE A DIAGNOSTIC IMAGING SERVICE? The MBS states that unless otherwise stated, a diagnostic imaging service specified in the Digital Imaging Service Table (DIST) may be provided by: (a) a medical practitioner; or (b) a person, other than a medical practitioner, who: (i) is employed by a medical practitioner; or (ii) provides the service under the supervision of a medical practitioner in accordance with accepted medical practice. However, for the purposes of Medicare the rendering practitioner is the medical practitioner who provides the report. Note our comments on item 56025 above, which requires a radiologist to report for that item number. RESTRICTIONS ON BULK BILLING Under section 20A of the Act and the MBS, if the diagnostic imaging service provider directly bills or bulk bills, he/she undertakes to accept the relevant Medicare Benefit as full payment for the service. Additional charges for that service (irrespective of the purpose or title of the charge) cannot be raised against the patient. Therefore, if the diagnostic imaging service provider bulk bills the patient, the diagnostic imaging service provider (and the relevant referring dental practitioner) cannot bill the patient for any additional amount for the same service. PROHIBITED DIAGNOSTIC IMAGING PRACTICES It is absolutely essential that you become familiar with the laws relating to pathology and diagnostic imaging services which are provided under Medicare. These laws prevent inducements or threats which may lead to referrals for pathology and diagnostic imaging services. The Act was amended in June 2007 by the Health Insurance Amendment (Inappropriate and Prohibited Practices and Other Measures) Act 2007 (Commonwealth) (the Amending Act). The main amendments of the Amending Act commenced on 1 March 2008. The Minister for Health and Ageing, the Hon Nicola Roxon MP, approved two Determinations -- one for pathology and one for diagnostic imaging: • Health Insurance (Permitted benefits -- diagnostic imaging services) Determination 2008; and • Health Insurance (Permitted benefits -- pathology services) Determination 2008. (the Permitted Benefits Determinations). The Department of Health and Ageing has also published a useful Explanatory Guide to the Health Insurance Amendment (Inappropriate and Prohibited Practices and Other Measures) Act 2007 in August 2007 and the publication Changes to Laws Relating to Pathology and Diagnostic Imaging. Further information is available on the Department of Health and Ageing website: www.health.gov.au. PROHIBITED CONDUCT The legislation applies to benefits (other than permitted benefits) and threats that are intended (whether by a provider or requester) to induce the requester to request pathology or diagnostic imaging services from the provider. The definitions of "requesters" and "providers" are very broad and penalties can include both civil and criminal penalties. A requester must not ask for or accept such a benefit and a provider must not offer or provide such a benefit. A benefit includes: • money, property or services, or any other benefit asked for, accepted, offered or provided in any form; and • an actual or a potential benefit. A person must not make such a threat. It is a criminal offence to ask for, accept, offer, or provide a benefit, or make a threat that is intended to induce requests to a particular provider. It is also unlawful to provide staff or equipment at a requester's premises for the purpose of providing pathology or diagnostic imaging services unless specifically permitted by the legislation. REQUESTERS A "requester", in relation to diagnostic imaging services means: • a medical practitioner; • a dental practitioner, chiropractor, physiotherapist, podiatrist or osteopath -- where that person referred patients to diagnostic imaging services for which Medicare Benefits are payable; • a person who employs or engages under a contract for services a person specified above; or • a person who exercises control or direction over a person specified above in his or her professional capacity. Therefore, if you employ or engage under a contract for services or exercise control or direction over a dental practitioner, you will be a requester under the Act. Whether or not you exercise control or direction over a person will be a question of fact. PROVIDERS A "provider" of diagnostic imaging services means: • a person who renders that kind of service; • a person who carries on a business of rendering that kind of service; • a person who employs or engages under a contract for services, a person specified above;
ADA News Bulletin November 2011
ADA News Bulletin February 2012