PHI 37/17 Clarification of Roles in the Certification Process

Page last updated: 19 July 2017

PDF Version: PHI 37/17 Clarification of Roles in the Certification Process (PDF 53 KB)

The Department has been made aware of systemic issues relating to the certification of Type B and C procedures. The issues are:

  1. Confusion and lack of awareness of certification requirements resulting in a lack of detail or incorrect information provided by hospitals and medical practitioners to insurers; and
  2. rejection of the medical conditions or special circumstances outlined in the certification documentation based on medical assessment by insurers.

The requirements for certification are set out in Schedule 1 Part 3 Sections 10 and 11 and Schedule 3 Part 2 Section 7 of the Private Health Insurance (Benefits Requirements) Rules 2011 (the Rules).

While there is no specified format for the certification documentation in order to meet the certification requirements it should include at a minimum:

  • sufficient information to identify the patient, the certifying medical practitioner and the specific medical procedure being certified;
  • details of the patient’s medical condition, or the special circumstances relevant to the specific procedure, that the medical practitioner is certifying require it to be performed in a hospital; and
  • a signed statement with wording to the effect that the medical practitioner certifies that it would be contrary to accepted medical practice to provide the procedure unless the patient is given hospital treatment that either includes (if certifying as Type B) or does not include (if certifying as Type C) part of an overnight stay.

Role of insurers

Insurers have an obligation to check the validity of certification documentation to ensure it meets the requirements as set out in the Rules and the procedure is covered by the patient’s private health insurance policy including checking pre-existing conditions, exclusions and waiting periods. However insurers should be aware that the Rules do not provide for any clinical assessment by insurers of the medical conditions/special circumstances certified by a medical practitioner.

Any insurer that rejects certification for any reason other than that they fail to meet the requirements prescribed in the Rules or that the proposed procedure is not covered by the patient’s health insurance policy is in breach of the Rules.

  • If there is insufficient or incorrect information in the certification to meet the requirements of the Rules or to determine if the procedure is covered by the patient’s policy, insurers should in the first instance, work with the hospital or medical practitioner providing the certification documents to seek further information.
  • Should insurers reject a medical procedure provided in a hospital setting that a patient believes is covered by their health insurance policy or there are unexpected out-of-pocket costs, patients can refer the matter to the Private Health Insurance Ombudsman (PHIO) for further investigation on 1300 362 072 or at phio.info@ombudsman.gov.au.

Role of medical practitioners/hospitals

Medical practitioners have an obligation to ensure they complete the certification documentation consistent with the requirements as set out in the Rules particularly they must specify either the:

  • medical condition of the patient (for example Haemophilia or for more complex cases provide more detail); or
  • special circumstances (for example a medical procedure on a young child or requirement for provision of general anaesthesia)
that, contrary to accepted medical practice, require the procedure to be conducted in hospital.

Certification documentation completed by a medical practitioner may be used by PHIO to assist in assessing whether, contrary to accepted medical practice, a medical procedure requires hospital treatment.

Examples of information that does not meet this requirement are shown below:

  • descriptions of the procedures performed (e.g. the MBS item description);
  • generic circumstances that are not specific to either the patient or the particular procedure (e.g. need to use sterile instruments, setting for patient safety and monitoring patient for adverse reactions); and
  • lack of equipment that might reasonably be expected to be provided in a medical practitioner’s consulting room (however the specific circumstances need to be taken into consideration, for example in rural/remote areas where no specialist consulting rooms are available, a hospital may be the only location with the necessary equipment).