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Medicare requirements for referrals to specialists and consultant physicians

The following information has been compiled to explain, in the simplest terms, the Medicare benefits rules for referrals and the implications of not adhering to them.

The following summary information has been compiled to explain, in the simplest terms, the Medicare benefits rules for referrals and the implications of not adhering to them.

References to the relevant legal provisions are also provided.

1. Referrals must be made in accordance with the regulations - Relevant Provision
2. Referrals must be in writing, signed by the referring practitioner and dated - Relevant Provision 
3. A referral covers a single course of treatment for a patient, being
                  -  the initial attendance by the specialist or consultant physician;
                  -  the continuing management/treatment until the patient is referred back to the care of the referring
                     practioner; and
                 -  any subsequent review of the patient’s condition that occurs within 9 months after the period
                    of validity of the last referral - Relevant Provision 
 
4. The period of validity of referrals is clear and can be managed by the practice without exposing the referring practitioner, specialist or consultant physician to penalties - Relevant Provision
5. Accounts for medical fees must contain particular information for a Medicare benefit to be paid - Relevant Provision
6. Accounts for referred services must contain the date on which the service was given and the date on which the patient was referred - Relevant Provision
7. Provision is made for situations when referrals are lost, stolen or destroyed - Relevant Provision 
8. Because the referral must be received before the service is provided, any back dating by the referring practitioner would be a false statement capable of being used to claim a benefit - Relevant Provision
9. There are 3 penalty provisions for making false or misleading statements capable of being used to claim a Medicare benefit. Knowingly making a false or misleading statement carries a much higher penalty than accidentally making a false or misleading statement - Relevant Provision

Referrals must be made in accordance with the regulations.

Health Insurance Act 1973

132A Regulations relating to the manner of patient referrals 

(1)    If an item specifies a service that is to be rendered by a practitioner to a patient who has been referred to the practitioner, the regulations may require that, for the purposes of the item, the patient is to be referred in a manner prescribed by the regulations.

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Referrals must be in writing, signed by the referring practitioner and dated.

Health Insurance Regulations 1975

29 Manner of patient referrals

(1) For section 132A of the Act, this regulation and regulations 30 and 31 set out the manner in which a patient is to be referred by a referring practitioner to another practitioner for the purposes of:

(a) an item in the general medical services table; or

(b) an item in a determination made under subsection 3C (1) of the Act; specifying a service to be rendered by a specialist or consultant physician, in the practice of his or her speciality, to a patient referred to the specialist or consultant physician.

(2) The referring practitioner must consider the need for the referral.

(3) The referral must give the specialist, or consultant physician, any information about the patient’s condition that the referring practitioner considers necessary.

(4) Unless subregulation 30 (1) or (2) applies, a referral must be:

(a) given in writing; and

(b) signed by the referring practitioner; and

(c) dated.

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Meaning of single course of treatment

Health Insurance (General Medical Services Table) Regulation

1.1.4 Meaning of single course of treatment

(1) Use this clause for:

(a)    items 104 to 131, 133, 384 to 388, 2799, 2801 to 2840, 3003, 3005 to 3028, 6004, 6007 to 6015, 16401, 16404, 16406, 51700 and 51703; and

(b)   the meaning of attendance in clause 1.1.1; and

(c)    the meaning of symbol (S) in clause 1.1.10; and

(d)   the definition of minor attendance in the Dictionary.

 (2) A single course of treatment for a patient:

(a)    includes: 

  (i)    the initial attendance on the patient by a specialist or consultant physician; and

 (ii)    the continuing management or treatment up to and including the stage when the patient is referred back to the care of the referring practitioner; and

(iii)    any subsequent review of the patient’s condition by the specialist or consultant physician that may be necessary, whether the review is initiated by the referring practitioner or by the specialist or consultant physician; but

(b)   does not include:

(i)      referral of the patient to the specialist or consultant physician; or

(ii)     an attendance (the later attendance) on the patient by the specialist or consultant physician, after the end of the period of validity of the last referral to have application under regulation 31 of the Health Insurance Regulations 1975 if:

(A)   the referring practitioner considers the later attendance necessary for the patient’s condition to be reviewed; and

(B)   the patient was most recently attended by the specialist or consultant physician more than 9 months before the later attendance.

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The period of validity of referrals is clear and can be managed by the practice without exposing the referring practitioner, specialist or consultant physician to penalties.

Health Insurance Regulations 1975 

31 Period of validity for referrals

(1)   Unless the period of validity for a referral is otherwise provided for in this regulation, the referral may state a period for which it remains valid and it will remain valid:

(a)   if the referral provides for it to be valid for a fixed period — for the period so provided after the first service given in accordance with the referral; or

(b)   if the referral provides for it to be valid indefinitely — for an indefinite period; or

(c)   if the referral does not provide for its validity — for 12 months after the first service given in accordance with the referral.

(1A)   A referral given by a specialist, or consultant physician, is valid:

(a)    if the referred patient is a patient in a hospital:

(i)  until the patient ceases to be a patient in a hospital; or

(ii) until 3 months after the first service given in accordance with the referral; whichever is the later; or

(b)   in any other case—until 3 months after the first service given in accordance with the referral.

(1B)   A referral given by a participating midwife is valid:

(a)    until 12 months after the first service given in accordance with the referral; and

(b)   for 1 pregnancy only.

(1C)  A referral given by a participating nurse practitioner is valid until 12 months after the first service given in accordance with the referral.

(2)    A referral given under subregulation 30 (1) is valid until the patient ceases to be a patient in the hospital who is not a public patient.

(3)    A referral given under subregulation 30 (2) or subregulation 30 (4) is valid for only 1 attendance on the patient.

(4)    A written referral that is lost, stolen or destroyed is valid for only 1 attendance on the patient.

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Accounts for medical fees must contain particular information for a Medicare benefit to be paid.

Health Insurance Act 1973 

19 Medicare benefit not payable in respect of certain professional services

(6) A medicare benefit is not payable in respect of a professional service unless the person by or on behalf of whom the professional service was rendered, or an employee of that person, has recorded on the account, or on the receipt, for fees in respect of the service or, if an assignment has been made, or an agreement has been entered into, in accordance with section 20A, in relation to the medicare benefit in respect of the service, on the form of the assignment or agreement, as the case may be, such particulars as are prescribed in relation to professional services generally or in relation to a class of professional services in which that professional service is included.

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Accounts for referred services must contain the date on which the service was given and the date on which the patient was referred.

Health Insurance Regulations 1975

13 Particulars to be recorded on accounts, receipts and bulk billing agreement

(1) For the purposes of subsection 19 (6) of the Act, the following particulars are prescribed in relation to professional services generally:

(a) the name of the patient to whom the service was given;

(b) the date on which the service was given;

(c) the amount charged in respect of the service;

(d) the total amount paid in respect of the service;

(e) any amount outstanding in respect of the service.

(4) For the purposes of subsection 19 (6) of the Act, the following particulars are prescribed in relation to professional services rendered by a consultant physician, or a specialist, in the practice of his or her specialty to a patient who was referred to that consultant physician or specialist in the manner prescribed in regulation 29 by a referring practitioner:

(a) the name of the referring practitioner;

(b) the address of the place of practice, or the provider number in respect of the place of practice, of the referring practitioner;

(c) the date on which the patient was referred by the referring practitioner to the consultant physician or specialist;

(d) the period of validity of the referral applicable under regulation 31.

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Provision is made for situations when referrals are lost, stolen or destroyed. 

Health Insurance Regulations 1975

13 Particulars to be recorded on accounts, receipts and bulk billing agreement

(6) For the purposes of subsection 19 (6) of the Act, the following particulars are prescribed in relation to professional services rendered by a consultant physician, or a specialist, in the practice of his or her specialty to a patient who has declared to the consultant physician or specialist that a referral referring the patient to that consultant physician or specialist has been completed by a referring practitioner, the name of the referring practitioner, and that the referral has not been delivered to the consultant physician or specialist due to the referral having been lost, stolen or destroyed:

(a) the name of the referring practitioner;

(b) the words ‘lost referral’;

(c) the address of the place of practice, or the provider number in respect of the place of practice, of the referring practitioner (if either of these are known to the consultant physician or specialist).

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Because the referral must be received before the service is provided, any back dating by the referring practitioner would be a false statement capable of being used to claim a benefit.

Health Insurance Reulation 1975

29 Manner of patient referrals

(5) Unless subregulation 30 (3) applies, the specialist or consultant physician must receive the referral before giving the service to the patient.

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There are 3 penalty provisions for making false or misleading statements capable of being used to claim a Medicare benefit. Knowingly making a false or misleading statement carries a much higher penalty than accidentally makinga false or misleading statement.  

Health Insurance Act 1973

125C Persons involved in contravening civil penalty provision 

(1) A person must not:

(a) aid, abet, counsel or procure a contravention of a civil penalty  provision; or

(b) induce (by threats, promises or otherwise) a contravention of a civil penalty provision; or

(c) conspire to contravene a civil penalty provision.

(2) A person who contravenes subsection (1) in relation to a civil penalty provision is taken to have contravened the civil penalty provision.

128A False statements relating to medicare benefits etc. 

(1) A person shall not make, or authorise the making of, a statement (whether oral or in writing) that is:

(a) false or misleading in a material particular; and

(b) capable of being used in connection with a claim for a benefit or payment under this Act.

Penalty: $2,000.

(2) Where:

(a) a person makes a statement (whether oral or in writing) that is false or misleading in a material particular;

(b) the statement is capable of being used in connection with a claim for a benefit or payment under this Act;

(c) the material particular in respect of which the statement is false or misleading is substantially based upon a statement made, either orally or in writing, to the person or to an agent of the person by another person who is an employee or agent of the first-mentioned person; and

(d) the last-mentioned statement is false or misleading in a material particular;that other person is guilty of an offence punishable on conviction by a fine not exceeding $2,000.

(2A) An offence under subsection (1) or (2) is an offence of strict liability.

Note: For strict liability, see section 6.1 of the Criminal Code.

(3) In subsection (2), a reference to an employee of a person shall, in a case where that person is a corporation, be read as a reference to:

(a) a director, secretary, manager or employee of the corporation;

(b) a receiver and manager of any part of the undertaking of the corporation appointed under a power contained in any instrument; or

(c) a liquidator of the corporation appointed in a voluntary winding up.

(4) A prosecution for an offence under this section may be commenced at any time within 3 years after the commission of the offence.

128B Knowingly making false statements relating to medicare benefits etc. 

(1) A person shall not make, or authorise the making of, a statement (whether oral or in writing) if the person knows that the statement is:

(a) false or misleading in a material particular; and

(b) capable of being used in connection with a claim for a benefit or payment under this Act.

Penalty: $10,000 or imprisonment for 5 years, or both.

(2) Where:

(a) a person makes a statement (whether oral or in writing) that is false or misleading in a material particular;

(b) the statement is capable of being used in connection with a claim for a benefit or payment under this Act;

(c) the material particular in respect of which the statement is false or misleading is substantially based upon a statement made, either orally or in writing, to the person or to an agent of the person by another person who is an employee or agent of the first-mentioned person;

(d) that other person knew that the last-mentioned statement was false or misleading in a material particular; and

(e) that other person knew, or had reasonable grounds to suspect, that the last-mentioned statement would be used in the preparation of a statement of the kind referred to in paragraph (b);that other person is guilty of an offence punishable on conviction by a fine not exceeding $10,000 or imprisonment for a period not exceeding 5 years, or both.

(3) In subsection (2), a reference to an employee of a person shall, in a case where that person is a corporation, be read as a reference to:

(a) a director, secretary, manager or employee of the corporation;

(b) a receiver and manager of any part of the undertaking of the corporation appointed under a power contained in any instrument; or

(c) a liquidator of the corporation appointed in a voluntary winding up.

(5) In this section, a reference to making a statement includes a reference to issuing or presenting a document, and a reference to a statement shall be construed accordingly.

129 False statements etc. 

(2) A person shall not furnish, in pursuance of this Act or of the  regulations, a return or information that is false or misleading in a material particular.

Penalty: $10,000 or imprisonment for 5 years.

(3) In a prosecution of a person for an offence against this section, it is a defence if he or she did not know, and had no reason to suspect, that the statement, document, return or information, made, issued, presented or furnished by him or her was false or misleading, as the case may be.

Note: The defendant bears an evidential burden in relation to the matter in subsection (3). See subsection 13.3(3) of the Criminal Code.

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