Operational Policy General Treatment Provider Recognition

Transcription

1 Purpose Health Partners ( the Fund ) pays benefits for treatment provided to its policy holders ( Members ) by Recognised Providers. To be recognised by Health Partners, Providers must meet the recognition criteria set out in this policy document. Health Partners has developed the following policies to ensure its members receive a professional standard of treatment and Health Partners funds are protected. Health Partners will assume Providers agree to all the terms and conditions in this policy each and every time one of its Members submits an eligible claim for professional services performed by the Provider, unless they inform the Fund otherwise. Scope This policy applies to all Providers currently recognised or wanting to be recognised by Health Partners for the payment of benefits. It incorporates both recognition and de-recognition policies. Definitions General Treatment Member Private Practice Participating Provider Network Patient Professional Body Provider The same meaning as set out in section of the Private Health Insurance Act 2007 or any amendment or replacement of it. A person who is a financial member of Health Partners with cover for General Treatment and in the case of a family membership, includes all dependents covered by that membership. A business in Australia that is self-supporting principally through fees received from patients and whose accommodation, facilities and services are not provided or subsidised by another party such as a public hospital or publicly funded facility. Selected Physiotherapy practices and pharmacies who have agreed to provide additional benefits for Members. A person receiving medical treatment by a medical/allied health professional. Means and includes: a) any registration board(s) that register health professionals under relevant Federal, State or Territory legislation, and is relevant to the Providers profession; b) any professional association relevant to the Providers profession; c) any court, tribunal, commission, board, committee or body that hears complaints relating to a breach of professional standards by members of the Providers profession. Health care professionals recognised by Health Partners for the purpose of the payment of benefits for general treatment provided to privately insured Australians. POLICY - Health Partners _May 2016 Page 1 of 10

2 Recognition Policy Recognition Criteria Health Partners Recognition criteria include meeting the requirements of the Private Health Insurance (Accreditation) Rules 2011, in addition to the Terms and Conditions set out on the following pages. It is a condition of Health Partners recognition that the Provider complies with all of the following terms: Be covered under the National Registration and Accreditation Scheme regulated by the Australian Health Practitioner Regulation Agency (AHPRA); Be a member of a national professional body/organisation or registration board for the type of treatment they provide; Hold a current Senior First Aid certification or equivalent for the entire duration of recognition with Health Partners and provide details of this certification upon initial application, and also upon expiry of the current certificate; Continuously hold current professional Indemnity Insurance along with public and product liability insurance to a minimum value of $1 million per claim, expressly for the services the Provider delivers to Health Partners members, and provide the Fund with a certificate of currency for this insurance; Provide professional service that complies with the standards for treatment specified in the Private Health Insurance (Accreditation) Rules 2011 or any amendment of those Rules if applicable to the Provider; Provide Health Partners with evidence of compliance to these Terms and Conditions by providing, on request, evidence of all relevant permissions, approvals, registrations, accreditations, qualifications, memberships, licenses, certifications and other forms of recognition required to support the Providers application; Provide services in private practice, and raise own accounts/receipts; Comply with all standards, guidelines, obligations and legislation relevant to the Providers profession for the services they provide to Health Partners members; Agree to allow Health Partners and its agents to make enquiries of any educational institution, professional association, registration body, government department or agency, statutory, semi-government or other body regarding the Providers professional education and qualifications and/or professional relationship, accreditation, registration, licensing, certification or other form of recognitions. Further, the Provider consents to and authorises the release to Health Partners or its agent s copies of all documentation, applications or reports related to those enquiries. Health Partners must be notified immediately if a professional body places any restrictions or limitations on the Providers registration or membership. Provide any relevant information requested by Health Partners relating to services performed by the Provider, in such circumstances as Health Partners has received the member s authority for this information to be released. This would include written, telephone and /or internet authorisation; Participate in Audit review: on request from Health Partners, allow Health Partners to audit provider records relating to service provided and benefit paid on behalf of Members; POLICY - Health Partners _May 2016 Page 2 of 10

3 Do not allow another person to perform services and invoice Health Partners or its Members using the Provider s number (with the exception of services performed by dental therapists, hygienists and oral health therapists where the Fund does not issue separate provider numbers and where the law permits this practice); Advise Health Partners of any changes to circumstances (eg. change of address/contact details, changes to business partnerships) within 7 days; Comply with any reasonable requests from Health Partners within stated time frames; Repay within 30 days of a Health Partners request for any monies paid where the Fund determines that the Provider was not entitled to it; Not display or otherwise use the Health Partners name or trademark, or represent any endorsement of approval of Health Partners, without Health Partners prior consent. Additionally, the Provider agrees to indemnify Health Partners against any claims in respect of personal injury (including death) to any person or damage to property in consequence of any negligence, whether by way of act, error or omission, or breach of any express term or term implied under The Sale of Goods Act, The Trade Practices Act or The Fair Trading Act, arising out of goods, services, advice and/or treatments provided by the Provider to a member of Health Partners, except to the extent of any unlawful or negligent act directly caused by or contributed by Health Partners or its agents. Health Partners may change the Health Partners Recognition criteria outlined in this policy document at any time, without notice. Provider Number(s) A provider number is unique and is specific to the individual Provider and the individual private practice location where the services are provided. Therefore Providers are required to have a specific provider number for each practice location. Health Partners relies on accurate provider contact details to communicate with health care providers. It is the Provider s responsibility to ensure that their provider number and practice address for each location is registered with Health Partners, and are accurate and up to date. Where a Provider Number is not available Complementary & Alternative Therapy Practitioners may apply on an individual basis using the Provider Recognition Application form. This form is available from the Health Partners website or by contacting the Fund directly. Health Partners will assess each application on merit, using specific recognition criteria and will inform the applicant of the result in writing. Orthotic and Orthopaedic Custom-made shoe Providers may also seek Provider Recognition with Health Partners by contacting the Fund directly. What Providers should expect from Health Partners As a Health Partners Recognised Provider, one can expect the Fund to pay claims for General Treatment services provided to its Members when: The Provider has complied with all terms and conditions outlined within this policy document; The Member lodges an eligible claim for General Treatment services or the Provider submits the claim electronically direct to Health Partners against the Member s policy with the fund that covers the said General Treatment; and The claim and services are in accordance with all Health Partners Fund Rules. POLICY - Health Partners _May 2016 Page 3 of 10

4 Health Partners may provide information to its members regarding a Provider s services and status as a Recognised Provider. This includes notification to members should recognition with Health Partners be suspended or withdrawn. Requirement for Health Partners to assess the benefit payable for manual claims All receipts/invoices must be in English and clearly identify: The Providers full name, practice address, telephone number and provider number, plus company trading name, ABN and/or ACN as applicable Where the Provider is part of a group, the account/receipt must include the name of the Provider who performed the service and their provider number (if applicable). Full name and address of the member who received the service The date each service was provided to the member Item number (if applicable) and description of the treatment provided (eg. initial consultation, standard consultation, etc) Date the account or invoice was issued Details of the fee/s charged for the treatment Details of amounts paid and outstanding balances Clearly state on the account/invoice if it is a duplicate, copy or where the document provided is a quote, it should be marked as Quote or Estimate. Samples of official accounts and receipts stationery, for each practice location, must be provided to Health Partners at the time of initial application and again should these documents be amended or requested in future. Health Partners requirements for electronic claims Health Partners require the following information to be correctly entered when processing a claim via electronic claiming: The member number as it appears on the Health Partners member card The person receiving the service/treatment as listed on the Member card (please note it is the Provider s responsibility to ensure that the person making an electronic benefit claim matches the name on the Health Partners member card) The service must be reflected against the Provider conducting the service Item number for service(s) rendered (the item number must accurately reflect the service rendered) Date which the service was provided (no benefits are paid in advance) Service(s) can only be claimed on the date the service was provided Fee charged for the service(s) provided. Discounts and no-charge services must be reflected in the service(s) costs entered into the electronic claiming terminal. Where there is more than one Provider at the practice and the member has seen one or more Providers during the same visit, a separate account for each Provider must be issued. Payment of Benefits Benefits are payable for: Services covered in accordance with the member s level of cover; Services provided to members by Health Partners Recognised Providers; and Services provided to Health Partners members in private practice. POLICY - Health Partners _May 2016 Page 4 of 10

5 Whether a benefit is paid for a service, remains at all times a decision for Health Partners in its discretion. When Health Partners may not pay a benefit In certain circumstances Health Partners may not pay a benefit for a claim made for a service. These include, but are not limited to, where those services are: Performed by practitioners who are not registered or recognised by Health Partners; Not administered by the Recognised Provider, which includes services administered by students working under the direct supervision and/or instruction of the Recognised Provider (with the exception of services administered by dental therapists, hygienist and oral health therapists where separate provider numbers are not issued and where the law permits this practice); Provided prior to approval date as a Recognised Provider; Not performed in a private practice setting, for example community health clinics; Provided to a member who is entitled to compensation or recovery from a third party, including but not limited to: Workers Compensation, Third Party Insurance, criminal compensation, Public Liability, etc; Provided to a member where the cost of the treatment/services is subsidised by any other business or authority, or where payment is sought from another source; For more than one consultation or attendance by the same Provider on the same day (excluding optical and dental services). Health Partners will pay for the first eligible service; For more than one initial consultation per course of treatment; Described inaccurately or where incorrect information about the service is supplied to Health Partners; Performed fraudulently; Illegal services, including imported medications. Other reasons Health Partners may not pay a benefit include, but are not limited to: The claimants membership is not financial or they are not covered for the service(s); The goods or services have not been provided to the member at the date of claim; The account and/or invoice receipt have been altered; The charge is for services not covered (eg. preparation of reports, telephone consultations); The charge is for medications or herbal tonics or similar; Health Partners receives independent medical or clinical advice and/or consider the service(s) inappropriate; Where it is determined that the Provider is charging different fees for insured members and non-insured patients, or members with different levels of Health Partners cover. Where those services are performed for a Provider s family member, a Provider s business partners, or other people who are not independent of the practice. Member Records For each Health Partners member treated, the Provider must maintain comprehensive, accurate clinical records which are made at the time of service and include, as a minimum: Member details including full name, date of birth, address and contact details; Date of each treatment; Nature of each treatment; POLICY - Health Partners _May 2016 Page 5 of 10

6 Nature of illness and/or reason for seeking treatment, plus; Any improvements, outcomes reached from the treatment. The clinical records are required to be maintained in English or must be translated into English at the Providers expense. Clinical records are to be retained in accordance with relevant legal requirements, including but not limited to, maintaining patient/member files in a manner which will ensure that all personal information is protected against misuse in accordance with National Privacy Principles as set out in the Commonwealth Privacy Act Where goods supplied have been specifically fabricated or customised for the sole use of an individual patient who is a Health Partners member, the Provider must retain a copy of any order forms and supplier invoices that relate to the goods and make these available when requested. This includes, but is not limited to: dentures, dental crowns, bridges, custom made orthoses and optical lenses. Provider Audit / Review Health Partners conducts regular reviews of its claims database in order to determine the treatment patterns of individual Providers as well as groups of Providers as a Quality Assurance Activity. On some occasions during the course of these reviews, it is necessary to seek further information from Providers in regards to claims and/or clinical records. In such circumstances the information will be requested in writing and it is a condition of ongoing recognition that the Provider complies with these requests and cooperates with Health Partners. Failure to comply with these requests may result in suspension or de-recognition. Health Partners may, depending on the nature of the review, contact its members subject to the claim. The Fund may not always contact the Provider prior to an approach of their patient, the Member. Further information is provided in the Review Process section within this document. De-Recognition Policy Health Partners seeks to ensure members receive a professional standard of treatment and that Health Partners funds are protected. Health Partners may decide to end its relationship with a Provider if they have not complied with the conditions specified by the Fund. This means they will no longer be a Recognised Provider and benefits will not be paid for the service(s) they provided to Health Partners members. Health Partners may immediately suspend or withdraw Provider Recognition at any time without discussion or prior notice, should there be evidence of any professional misconduct, and/or breach of the Terms and Conditions as set out in this policy document, and/or fraud, whether proven or reasonably suspected. POLICY - Health Partners _May 2016 Page 6 of 10

7 Reasons for De-Recognition De-Recognition of a Provider may occur when: a) Health Partners has received higher than normal complaints from members in relation to the Provider, or members complaints are of a nature that would be of concern to other members of the fund; b) a Provider is excessively costly to the fund as a result of inappropriate billing for example, over-servicing or incorrect or problematic coding, or where codes or item numbers do not accurately reflect the treatment provided; (may be identified through Provider Audit) c) a Provider violates the rules, or does not maintain a code of conduct, which the Provider must uphold in order to continue to be a member of their appropriate board or association. d) a Provider is no longer registered by the appropriate board or association; e) the Provider is creating a risk to the fund; or f) the Provider committed or is suspected of committing, Fraud. Suspending or ending Health Partners relationship with a Provider may also occur if the Provider has not complied with the conditions specified by Health Partners arising from: a) The requirements set out in this document and any other document describing the relationship between Health Partners and the Provider, including failure to participate fully in the Provider Audit process; b) The requirements set out by the Electronic Claiming Provider; c) Any Health Partners Fund Rules; d) Any other requirements as advised by Health Partners from time to time. In its discretion, Health Partners may also consider de-recognising a Provider if their facilities don t meet the standards determined or required by Health Partners and the Australian Health Practitioner Regulation Agency. Health Partners may terminate a Provider by giving 28 days notice in writing to them advising that the services they provide do not meet or cease to meet, the standards for treatment specified in rules 7 (1), 8 or 9 of the Private Health Insurance (Accreditation) Rules 2011 or any amendment or replacement of them (Rules) Health Partners may suspend or withdraw Provider Recognition at its discretion, at any time for reasons other than those mentioned above, by giving 28 days notice in writing. Providers must notify patients/clients of theirs who are Health Partners members as soon as practicable in the event that recognition by Health Partners is suspended or withdrawn. Impact of Provider De-recognition The consequence of a Provider being de-recognised is that Health Partners will cease to pay fund benefits in relation to services provided by that Provider. Health Partners members may choose to continue treatment with the Provider, however members will not be eligible for fund benefits in relation to the treatment or services provided. Health Partners reserves the right to refer the matter to a state registration board or relevant association. POLICY - Health Partners _May 2016 Page 7 of 10

8 Review Process A healthcare Provider may be selected for review after a profile analysis (statistical and/or clinical) or on the basis of other information received by Health Partners which indicates further investigation may be necessary. Where Health Partners believes there are grounds for concern as a result of this analysis or information, Health Partners may, in its reasonable discretion, forward the Provider s details to Health Partners external clinical adviser where the concern is of a clinical nature. Where Health Partners considers that the circumstances are sufficiently serious, Health Partners may decide to place the Provider under audit. While the audit is being completed all claims will be referred to a claims manager or provider administrator for approval and Health partners may also suspend the Providers electronic claiming status. Health Partners may ask its members to verify any recent service. Members may also be asked to attend a clinical examination by a Health Partners contracted clinical adviser where the concern is of a clinical nature. Health Partners may also question members on the nature of the treatment and the manner in which these treatments were performed. Investigating method Where Health Partners considers that circumstances are sufficiently serious to warrant further investigation, Health Partners will in its discretion, either: a) Invite the Provider to take part in a conciliation session with Health Partners and/or a clinical adviser contracted by Health Partners. If the original issues of concern are not resolved, or the Provider does not alter his/her behaviour to Health Partners reasonable satisfaction after two conciliation sessions, the Provider may be de-recognised. Conciliation sessions will be scheduled to take place at 2 month intervals; or b) Write to the Provider and request that the Provider submit a written response to the issues of concern raised by Health Partners. If the original issues of concern are not resolved, or the Provider does not alter his/her behaviour to Health Partners reasonable satisfaction after receiving two letters from Health Partners addressing the issues of concern, the Provider may be de-recognised. Conciliation session Health Partners may decide that a conciliation session is required in order to further conduct its investigation in accordance with this policy. Health Partners will write to the Provider requesting the Provider attend a conciliation session with Health Partners and/or clinical adviser where Health Partners concern, or one of its concerns, is clinical in nature. The letter will specify: a) The areas of concern; b) Who will be at the meeting; and c) The proposed date for the meeting which will be at least 28 days from the date of the letter. Where possible, Health Partners and the Provider will agree on a mutually convenient time for the meeting. Health Partners will, at all times, be reasonable however only in exceptional circumstances will the meeting be scheduled for a time outside of normal business hours. POLICY - Health Partners _May 2016 Page 8 of 10

9 Notice Approximately 14 days prior to the meeting the Provider will be sent a letter outlining the details that are the subject for discussion and the Provider will be asked to bring relevant records for reference. For the avoidance of doubt, Health Partners By-laws and the Health Partners Privacy Policy which governs the handling of Health Partners members personal information will be adhered to throughout this process. Health Partners Privacy Policy can be accessed and viewed at Health Partners website Who can attend The Provider is entitled to have an observer with them and may choose to bring a representative from his/her professional association or his/her lawyer. This is at the Provider s discretion and cost. If the Provider intends to bring a lawyer to the conciliation session, notice must be given to Health Partners at least 7 days prior to the conciliation session. This is to allow Health Partners to determine whether their own legal representation will be required. Ongoing issues Health Partners will provide a copy of any continued concerns or the relevant part of the conciliation report, to the Provider within 28 days after the date of a conciliation session. At this time Health Partners may also request further information. Health Partners will allow a minimum of 28 days for the Provider to respond to any concerns or issues raised and to provide further information, if requested. Health Partners will take into account the Providers response and further information, if any, before a decision is made. If no response is received from the Provider within the allocated timeframe, Health Partners will make a decision as to any further action in relation to the Providers recognition status, including but not limited to, de-recognising the Provider. Failure or refusal to attend a conciliation session or indication of a Provider s intention not to attend the conciliation session will result in the Provider remaining under audit. The Provider will be given a second opportunity to respond to the concerns or issues within 28 days from the first scheduled conciliation session. Failure to attend the second conciliation session will result in the Provider being de-recognised immediately. Fraud Health Partners will identify whether a Provider has committed fraud by reviewing information which may have been ascertained as a result of: a) court prosecution; b) state professional board deregistration; or c) Health Insurance Commission suspension by Professional Review Division. Health Partners may also take steps on the basis that it has reasonable grounds to suspect fraud. These grounds may arise from: a) Member complaint; b) Claim audit (auto claim, claims data, statistical analysis, random audit of members for service validation); or c) Information gained from any other source. POLICY - Health Partners _May 2016 Page 9 of 10

10 In the case of allegation of fraud, which includes the aiding and abetting of fraud, Providers will be given the opportunity to answer the allegations in writing, whether these allegations have been made by the fund or its members, prior to Health Partners making its final determination. Fraud investigation In circumstances where fraud is suspected, the Provider will be asked to respond to the allegation of fraud in writing within 28 days. Health Partners may ask members to verify any recent services received and members may also be asked to attend a clinical examination by a Health Partners adviser where the grounds for concern are clinical in nature. Health Partners will consider all information and make a decision within 28 days of the date on which the Provider submitted their response to the allegation. It is extremely likely that a Provider who has been prosecuted, de-registered or suspended on the grounds of fraud will similarly be de-recognised by Health Partners. Participating Provider Networks Physiotherapy & Pharmacy Health Partners provides a Physiotherapy Participating Provider program that offers members a guaranteed lower set gap payment when obtaining services from authorised participating practices. Each practice is specifically chosen to ensure access and quality services in agreed geographical areas. Health Partners also maintains a comprehensive Pharmacy network across metropolitan and regional South Australia, which offer unique benefits and discounts available to all of its Extras and Package members at no extra cost. In addition to abiding by the terms and conditions as set out in this Recognition Policy, Participating Providers are also subject to additional contractual requirements. Providers seeking more information about the Physiotherapy or Pharmacy Participating Provider programs, or to enquire about joining a Provider program, please contact Health Partners. Policy Review The terms and conditions as set out within this policy document are subject to change at any time, without notice, to ensure the upmost quality of service is provided to its members. Providers should keep themselves informed by regularly checking the Provider section of the Health Partners website for notices of any changes. Providers who are part of the Health Partners Participating Provider Network will be advised of any changes to their specific contracts in writing, as per the Notice clause of their individual contracts. Related Documents Provider Recognition application form (Complementary and Alternative Therapy Practitioners, Orthotists and Medical Grade Footwear Manufacturers) Orthotics Provider Recognition form Health Partners Fund Rules POLICY - Health Partners _May 2016 Page 10 of 10