Guide to Optimising Own Source Revenue

Transcription

1 Guide to Optimising Own Source Revenue Document Number # QH-GDL-004:2012 Custodian/Review Officer: Director, Own Source Revenue Unit Version no: 1 Applicable To: Provides guidance to Health Service Districts Approval Date: 26/06/2012 Effective Date: 01/07/2012 Next Review Date: 30/06/2015 Authority: Deputy Director-General Finance Procurement and Legal. Approving Officer Deputy Director-General Finance Procurement and Legal. Supersedes: New Guideline Key Words: key words to describe the document Accreditation References: EQuIP and other criteria and standards 1. Purpose This Guideline provides recommendations regarding best practice for optimising Own Source Revenue through: Consistently identifying and collecting Own Source Revenue; Minimising the leakage of Own Source Revenue including reducing unrecoverable debt; Regularly reviewing policy effectiveness to promote continuous improvement. 2. Scope This Guideline provides information for all Queensland Health employees (permanent, temporary and casual) and all organisations and individuals acting as its agents (including Visiting Medical Officers and other partners, contractors, consultants and volunteers). 3. Related documents Legislative or other Authority Hospital and Health Boards Act 2012; Hospital and Health Boards Regulation 2012; Health Service Directive: Own Source Revenue Central Coordination of Fees and Charges Increases and Category C Negotiation and Acquisition; Aged Care Act 1997; Financial Management Standard 1997; Guardianship and Administration Act 2000; Health Insurance Act 1973; Motor Accident Insurance Act 2003; Powers of Attorney Act 1998; Private Health Insurance Act 2007; Private Health Insurance (Benefits Version No.: 1.0; Effective From: 1 July 2012 Page 1 of 19

2 Requirements) Rules; Private Health Insurance (Prostheses) Rules; Public Service Act (Qld) 2008; Right to Information Act 2000; Workers Compensation and Rehabilitation Act Related policy or documents Council of Australian Governments (COAG) Section 19(2) Exemption Statewide Guidelines; Financial Management Practice Manual (FMPM); National Healthcare Agreement 2011; National Health Reform Agreement; Q-Comp Public Health Services Table of Costs; Q-Comp Medical Items Schedule of Fees; Queensland Health Code of Conduct; Queensland Health Fees and Charges Register; QH Funding Model Business Rules and Guidelines ; Rural and Remote Medical Benefit Scheme (RRMBS) Business Rules; Hospital and Health Services OSR Procedures and Guidelines. Forms and templates Patient Election Form 4. Guideline for optimising Own Source Revenue 4.1 Principles Prioritisation for clinical treatment is based on assessed clinical need: identification of funding source is secondary to clinical need. District management: Own Source Revenue is a significant budget component and remains the responsibility of the Hospital and Health Services (HHS) to identify and collect. Own Source Revenue activity is incentivised: Own Source Revenue generated from patient treatment over set target levels will be retained by the HHS to manage their budget. Improved patient care: optimisation of Own Source Revenue assists in funding improvements to public patient care. Accurate allocation: Own Source Revenue generated by a HHS remains within that HHS. Transparency: the identification, collection and reallocation of Own Source Revenue through Queensland Health is a transparent process. Service improvement: access to relevant, accurate and timely data will allow performance reporting and analysis to be undertaken on a regular basis. Financially sustainable healthcare system: optimising Own Source Revenue is necessary to ensuring a financially sustainable healthcare system. Version No.: 1.0; Effective From: 1 July 2012 Page 2 of 19

3 4.2 Requirements Patient Care and Own Source Revenue Identifying a funding source is secondary to clinical need. Identifying Own Source Revenue assists to maintain the required level of patient care Identify Funding Sources: Who is going to pay for this? To enable efficient reimbursement for services, Hospital and Health Services staff are required to correctly record all patient activity data. HHS staff are required to administer a Patient Election Form (PEF) for all admitted patients, or assist a patient to complete the form to ensure patient details are accurately and completely recorded to enable the appropriate funding source to be identified. Patient Election Form To meet the obligations under the National Health Reform Agreement, Hospital and Health Services staff are required to: o Provide all inpatients with the PEF and assist inpatients in completing the form if required (National Health Reform Agreement (G14, G18 and G24)). Note: non-admitted patients do not have to express their choice in writing; o Provide all inpatients with the document Public or Private Your Choice (Your Election) and assist the patients in reading and/or understanding this information if necessary, to support the patient in making an informed choice to be treated as either a public or private patient (National Health Reform Agreement (5C and G15) and (G18a)); o not direct patients or their legal guardians towards a particular choice (National Health Reform Agreement (G18b)) Determining Medicare Eligibility To determine the patient s entitlement to receive services at no cost as a public patient, Hospital and Health Services staff need to assess Medicare eligibility for all persons presenting to HHS facilities. For admitted patients, Medicare eligibility is recorded in Section A on a PEF. Medicare eligible patients presenting to emergency departments at a HHS facility are to be treated as public patients before any clinical decision is made to admit (National Health Reform Agreement G18). HHS staff will give Medicare eligible patient the choice to elect to be a public or private patient. This election is exercised in writing before, at the time of, or as soon as possible after admission (National Health Reform Agreement G14). Compensable patients are excluded from eligibility for Medicare in relation to public hospital services. HHS are entitled to raise charges for services provided to compensable patients. Compensable patients fall into three (3) broad categories: Version No.: 1.0; Effective From: 1 July 2012 Page 3 of 19

4 - Motor Vehicle Accident patients - Workers Compensation patients - Other Third Party patients Public Patients In general, Medicare eligible public patients are not invoiced except for charges documented in Schedule G of the National Health Reform Agreement as follows: - G1 Where an eligible person receives public hospital services as a public patient no charges will be raised, except for the following services provided to non-admitted patients and, in relation to (f) only, to admitted patients upon separation: a. dental services; b. spectacles and hearing aids; c. surgical supplies; d. prostheses however, this does not include the following classes of prostheses, which must be provided free of charge: i. artificial limbs; and ii. prostheses which are surgically implanted, either permanently or temporarily or are directly related to a clinical necessary surgical procedure; e. external breast prostheses funded by the National External Breast Prostheses Reimbursement Program; f. pharmaceuticals at a level consistent with the PBS statutory copayments; g. aids, appliances and home modifications; and h. other services as agreed between the Commonwealth and States. - G2. States can charge public patients requiring nursing care and accommodation as an end in itself after the 35 th day of stay in hospital providing they no longer need hospital level treatment, with the total daily amount charged being no more than 87.5 per cent of the current daily rate of the single aged pension and the maximum daily rate of rental assistance Patients Funded by a Third Party (Non-public Patients) Private Patients (refer to glossary for definition) Under the National Health Reform Agreement (G24 (e)), HHS staff are required to ensure all patients understand the implications of their election including the financial aspects. Accommodation fees for private patients are contained in the Queensland Health Fees and Charges Register ( Professional medical services provided are based on the Schedule of Fees listed in the Medical Benefits Schedule. Version No.: 1.0; Effective From: 1 July 2012 Page 4 of 19

5 The PEF is used to document the patient choice to elect to be treated as a private or public patient Department of Veterans Affairs (DVA) Patients When identifying DVA patients, HHS staff will need to document the following: - DVA number; - DVA repatriation card level (gold or white). For White Card Holders HHS staff can contact DVA to ensure the condition the patient is being treated for is covered by DVA. If the patient s treatment is not covered under DVA, HHS staff can use the PEF to identify the patient s appropriate funding source Department of Defence (DD) Patients Under all circumstances, the DD patient remains classified as DD whether or not consent is given to release information to the DD. No fees are raised for treatment of public DD patients. Fees are raised with the DD for private DD patients in shared room accommodation in accordance to the Queensland Health Fees and Charges Register Work Related Injury or Illness: Workers Compensation Patients Under the National Health Reform Agreement (G3), Workers Compensation patients are charged an amount as determined by Queensland Health (Refer to the Queensland Health Fees and Charges Register). A Workers Compensation insurer will not pay for the patient to be treated as a private patient unless prior approval has been obtained. If approval is not obtained or the claim is rejected, the patient is liable for any fees. Where the patient is Medicare eligible and their Workers Compensation claim has been rejected by the insurer, the patient who elected to be treated as public Workers Compensation is entitled to revert to Medicare eligible public status. Where the patient successfully takes out a motor vehicle accident claim under the Motor Accident Insurance Commission (MAIC) grant, the Workers Compensation insurer will be reimbursed for the cost of the treatment WorkCover Queensland In situations where WorkCover Queensland granted prior approval for the injured worker to be treated as a private patient, an invoice is raised by the HHS facility and forwarded to WorkCover Queensland for the cost of services. Charges are raised by the facility in accordance with the Queensland Health Fees and Charges Register and Q-Comp Medical Items Schedule of Fees. Payment for services provided to WorkCover Queensland public patients are collected by the State-wide Own Source Revenue Unit under an annual advanced payment and distributed to the HHS. Version No.: 1.0; Effective From: 1 July 2012 Page 5 of 19

6 Queensland Workers Compensation Self-insurers HHS Revenue staff raise fees for any public Workers Compensation admitted or non-admitted services and forward to the appropriate Queensland Workers Compensation self-insurer. Fees are raised in accordance with the Q-Comp Public Health Services Table of Costs and Q-Comp Medical Items Schedule of Fees. Where prior approval has been granted from Queensland self-insurer for the patient to be treated as a private patient, an invoice is raised by the facility and forwarded to the Queensland self-insurer for cost of the services. Fees are raised by the facility in accordance with the Queensland Health Fees and Charges Register and Q-Comp Medical Items Schedule of Fees. ( Workers Compensation Other HHS Revenue staff raise invoices for admitted services provided to Workers Compensation patients insured by non-queensland Workers Compensation insurers such as interstate and federal insurers. Fees are raised in accordance with the Queensland Health Fees and Charges Register not in accordance with fees set by the particular Workers Compensation authority of the Commonwealth or other states. Where prior approval has been granted from non-queensland Workers Compensation insurer, for the patient to be treated as a private patient, an invoice is raised by the facility and forwarded to the insurer for cost of the services. Fees are raised by the HHS facility as listed in the Queensland Health Fees and Charges Register. For the non-admitted Workers Compensation Other patient fees will be raised as Compensable/Third Party non-admitted in accordance with the Queensland Health Fees and Charges Register. ( Motor Vehicle Accident Insurance Patients Fees are not raised for public Motor Vehicle patients (MVQ), where the fault lies with the driver of a Queensland registered vehicle. Reasonable costs for these patients are covered under the Motor Accident Insurance Commission (MAIC) Hospital and Emergency Services Levy. Payment for services provided to Motor Vehicle Queensland public patients (MAIC Grant) is collected by the Revenue Unit and distributed to the HHS as per the Own Source Revenue Budget Allocation Methodology based on actual Own Source Revenue activity recorded by the HHS. HHS Revenue staff can raise fees to the patient s insurer for Motor Vehicle patients (MVO), where the fault lies with the driver of a motor vehicle registered in a state or territory other than Queensland. Version No.: 1.0; Effective From: 1 July 2012 Page 6 of 19

7 Third Party Compensable Patients (Personal Injury Claims) Third party compensable patients are charged an amount for public hospital services in accordance with the Queensland Health Fees and Charges Register. Note: This excludes any cases where the patient has been paid under another scheme such as MAIC or Queensland workers compensation Section 19(2) Exemptions in Queensland An exemption from Section 19(2) of the Health Insurance Act 1973 (Cwth) enables Medicare rebates to be claimed for state-remunerated primary health care services (for non-admitted and non-referred patients). The Medicare revenue raised under these initiatives is to be used for primary health care enhancements at the sites in which the Medicare revenue is generated. There are three separate Section 19(2) exemptions from the Health Insurance Act 1973 (Cwth) operating in Queensland: - Inala Indigenous Health Service has been operating their exemption since This applies to the Primary Health Care Centre which operates in the Inala community servicing a large percentage of Indigenous patients. The exemption was recently extended to also cover Carole Park. - Rural and Remote Medical Benefits Scheme (RRMBS) specific to rural and remote communities with a high proportion of Indigenous people. - Council of Australian Governments (COAG) 19(2) exemption for small rural and remote communities with less than 7,000 people with an identified GP workforce shortage Visitors to Queensland or Non-Permanent Resident Overseas Visitors/Student Patients If the overseas visitor is from a Reciprocal Health Care Agreement (RHCA) country they are entitled to free medically necessary treatment as a public patient in a public health facility. If the overseas visitor is not from a RHCA country, then the visitor is not eligible for Medicare or free public health services and fees are raised against this patient. 457 Visas It is a condition of a 457 visa that all holders will maintain adequate arrangements for health insurance for themselves and their families for the duration of their stay in Australia. However, if the patient is from a RHCA country they must arrange adequate insurance for an initial period in Australia, but once enrolled with Medicare this is considered sufficient to comply with visa health insurance requirements. Version No.: 1.0; Effective From: 1 July 2012 Page 7 of 19

8 Student Visas Queensland Health: Guideline: Guide to Optimising Own Source Revenue It is a condition of the student visa that all students take out Overseas Student Health Cover (OSHC). However, if the patient is in Australia on a student visa from the UK, Sweden, the Netherlands, Belgium, Slovenia or Italy they are covered by Medicare. Students from Norway, Finland and Malta are not covered under a RHCA. Medical Visas HHS staff raise fees for patients who enter Australia for the purposes of medical treatment under a Medical Treatment Visa (Medical Treatment Short Stay (675 visa) or Medical Treatment Long Stay (685 visa). These patients pay the full cost of their medical treatment (e.g. fees for consultation, treatment, diagnostics and hospital accommodation). These patients are required to make adequate payment arrangements prior to treatment Asylum Seekers, Detainees and Refugee Patients Department of Immigration and Citizenship (DIAC) cover the cost of services provided by HHS to immigration detainees as per the MOU (file ref. DG052761). Invoices for Detainees are forwarded to International Health and Medical Services at the Medicare ineligible rates as listed on the Queensland Health Fees and Charges Register, or on a cost recovery basis. HHS Revenue staff negotiate and agree to the fees with the Department of Immigration and Citizenship prior to the provision of service where fees for services provided under the MOU are not prescribed under the Queensland Health Fees an Charges Register ( HHS Revenue staff can write off fees raised in the treatment of Medicare ineligible asylum seekers (as documented in the Financial Management Practice Manual). Refugees have had their status acknowledged and therefore have access to Medicare Interstate Patients (Cross Border) HHS staff can identify interstate patients through accurately recording of the patient s permanent residential address and postcode. HHS Revenue staff can not raise fees against public interstate patients. Staff can raise fees to the private health fund or patient (self-funded) for an interstate patient electing to be treated as a private patient. HHS staff will forward all non-admitted data to the Revenue Unit annually. The State-wide Own Source Revenue Unit will collect state-wide inpatient data for patients of all jurisdictions from the Health Statistics Centre. Queensland data is reconciled with other states data in order for Queensland cross-border payments to be identified and either recovered from or paid to other states and territories. Version No.: 1.0; Effective From: 1 July 2012 Page 8 of 19

9 The Revenue Unit will undertake cross-border recoveries and payments and make any reimbursements to the HHS as per the Own Source Revenue Budget Allocation Methodology based on actual Own Source Revenue activity reported by the HHS Miscellaneous Issues Inter-facility Transfers HHS are provided with a budget to cover their annual inter facility transfer costs based on the previous year s activity. This also includes funding for DVA interfacility transfers. The HHS can check the invoice for inter-facility transport costs and exclude any MAIC 1 or Cross Border 2 patients. HHS can seek reimbursement from insurers for Queensland Workers Compensations 3 and Medicare Ineligible patients 4. HHS are not entitled to claim for Department of Veterans Affairs patients interfacility transfers but are required to keep accurate data on these services Surgically Implanted Prostheses Medicare Eligible Private Patients with Private Health Insurance The treating surgeon is required to ensure that a non-public patient is provided with informed financial consent prior to surgery. This information should cover the patient s liability for any charges not covered by their health insurer for any prosthesis items (Commonwealth Informed Financial Consent Guidelines (PHI 63/05)). Prostheses items other than Cardiothoracic and Ophthalmic will be reimbursed at the rate of the minimum benefits listed in the Schedule in the Private Health Insurance (Prostheses) Rules (Cwth). No supplier s invoice is required by the Private Health Insurers to reimburse the facility. Reimbursement from Private Health Insurers for gap permitted prostheses is the minimum benefit from the Schedule in the Private Health Insurance (Prostheses) Rules (Cwth) or the amount of the insured person s liability to the public hospital for that prosthesis whichever is the lesser. Any prosthesis charge above the benefit level paid by the private health fund is the private patient s responsibility. All Cardio-thoracic items in the Schedule will have a discount of 7.5% to the current minimum benefit amount in the Schedule in the Private Health Insurance (Prostheses) Rules (Cwth) at the time of processing. No supplier s invoice is required by the Private Health Insurer to reimburse the facility. 1 MAIC patients the emergency services such as ambulance services are provided with a MAIC grant from the Hospital and Emergency Levy of CTP to cover the reasonable costs. 2 Cross-border patients Queensland Ambulance Service has agreements with their counterparts in other states. 3 Queensland Workers Compensation insurers include WorkCover Queensland will reimburse the facility for costs of the inter-facility transfer. 4 Medicare ineligible patients or their insurer shall reimburse the facility for costs of the inter-facility transfer. Version No.: 1.0; Effective From: 1 July 2012 Page 9 of 19

10 All Ophthalmic items in the Schedule shall have a discount of 20% to the current minimum benefit amount in the Schedule in the Private Health Insurance (Prostheses) Rules (Cwth). No supplier s invoice is required by the Private Health Insurer to reimburse the facility. If the cost to a hospital of an item number for Cardio-thoracic or Ophthalmic is above discount level, the hospital can claim a higher amount by providing a supplier invoice to the private health insurer. The private health Insurer will reimburse at the invoice cost up to the minimum benefit level (given the additional administrative and financial cost of procuring and sending an invoice to a fund, it is expected that hospitals will only provide an invoice where the cost is significantly above the discounted level). Eligible Private Patient without Private Health Insurance The patient will pay full cost recovery rate unless they are a permanent Queensland resident pensioner. Permanent Queensland resident pensioners who choose private status and are self-funded (that is, not using private health insurance) can receive their surgically implanted prostheses free of charge. Eligible Department of Veterans Affairs Patients HHS revenue staff can raise charges for prosthesis provided to eligible veterans at the lesser of: (a) Invoice cost to the hospital direct from the supplier; or (b) Schedule price. Where the HHS is invoiced at an amount in excess of the Schedule price, the DVA Contract Manager can be contacted directly by the facility and DVA will address the matter with the supplier. DVA reserves the right to view the relevant supplier invoices. Medicare Ineligible and Third Party Compensable (excluding MAIC) Patients The Third Party Compensable patient will be invoiced for full cost recovery except for a MAIC patient. MAIC patient costs are covered under the MAIC Grant Arrangements Acute Care Certificates A patient regardless of their funding source who remains acute after 35 days continuous hospitalisation will be issued with an Acute Care Certificate. A patient who remains in hospital for over 35 days and is not the subject of an Acute Care Certificate will be assigned as a Nursing Home Type Patient (NHTP) and charged a fee as per the Queensland Health Fees and Charges Register. The 35 day period: - may accrue in more than one hospital (public, private or both) - excludes leave days Version No.: 1.0; Effective From: 1 July 2012 Page 10 of 19

11 - commences upon admission The 35 day period does not apply if the patient was a resident of a residential care facility immediately before admission to a public psychiatric hospital. If however the patient was a resident of a residential aged care facility and is admitted to hospital under the acute care type, remains under this care type for more than 35 day and is not covered by an Acute Care Certificate the patient must be classified as NHTP Newborns and Fees All babies aged nine days or less shall be admitted as newborn episode of care which continues until the care type changes or the patient is separated. A newborn is given a qualification status as either qualified (previously recorded as acute ) or unqualified. Newborns attract a fee where the baby is given a qualification status of qualified and is: - Medicare ineligible; or - Medicare eligible and treated as a private patient. A qualified status is given to a newborn if they are nine days old or less and meet one of the following criteria: - the newborn is the second or subsequent live born infant of a multiple birth; - the newborn is admitted to a special care facility in a hospital, being a facility approved by the Australian Government Health Minister for the purpose of the provision of special care (i.e. a special care nursery ); or - the newborn is in hospital without its mother. A newborn is assigned an unqualified status if they are nine days old or less and do not meet the criteria for being admitted as qualified. Still born babies are not admitted. For further clarification for newborns refer to the Queensland Hospital Admitted Patient Data Collection (QHAPDC) Communicable Diseases The diagnostic and treatment services for tuberculosis and leprosy are provided free of charge to a patient. This includes medications required to treat tuberculosis and leprosy. The provision of free diagnostic and treatment services and medications for tuberculosis and leprosy suffers extend to Medicare ineligible patients. Version No.: 1.0; Effective From: 1 July 2012 Page 11 of 19

12 5. Definition of Terms Definitions of key terms are provided below. Term Definition / Explanation / Details Source Asylum Seekers The Department of Immigration and Citizenship defines an asylum seeker as an individual who is seeking international protection. In countries with individualised procedures, an asylum seeker is someone whose claim has not yet been finally decided on by the country in which he or she submitted the claim. Not every asylum seeker will ultimately be recognised as a refugee, but every refugee is initially an asylum seeker (United Nations High Commission for Refugees, Master Glossary of Terms, June 2006). In the Australian context, this means that an asylum seeker is a Protection visa (PV) applicant until his or her application has been finally determined by the Department of Immigration and Citizenship ('the department') or the Refugee Review Tribunal (RRT). See: Fact Sheet 61 - Seeking Asylum within Australia Community Detention Community detention is a form of immigration detention that enables people in detention to reside and move about freely in the community without needing to be accompanied or restrained by an officer under the Migration Act edia/factsheets/82detention.htm#i Compensation damages or compensation or damages, in relation to a third party patient, includes payment in settlement of a claim for compensation or damages, but does not include (a) compensation under (i) the Criminal Offence Victims Act 1995, part 3; or (ii) the Youth Justice Act 1992, section 235; or (iii) the Penalties and Sentences Act 1992, section 35; or (b) an amount under (i) a policy of insurance, under the Motor Accident Insurance Act 1994, for which the insurance premium consists of the matters mentioned in section 12(1) of that Act; or (ii) the Nominal Defendant scheme under that Act; or (c) financial assistance under the Victims of Crime Assistance Act 2009, chapter 3. Health Services Regulation 2002 (Qld) Schedule 3 Version No.: 1.0; Effective From: 1 July 2012 Page 12 of 19

13 Term Definition / Explanation / Details Source Compulsory Party Insurance Detainees Third (CTP) Queensland operates a common law fault based Compulsory Third Party (CTP) scheme. The scheme provides motor vehicle owners with an insurance policy that covers their unlimited liability for personal injury caused by, through or in connection with the use of the insured motor vehicle in incidents to which the Motor Accident Insurance Act 1994 applies. Australia's Migration Act 1958 requires that unlawful non-citizens who are in Australia's migration zone be detained and that unless they are granted permission to remain in Australia, they must be removed as soon as reasonably practicable. u/ edia/factsheets/82detention.htm#i Discount Front-end Deductibles Discount Immigration Detention Centres Discount is an incentive offered to patients to encourage use of their private health insurance without consideration of financial hardship. Includes discounting of private hospital insurance policy excess and/or patient co-payments. Immigration Detention Centres primarily accommodate people who have overstayed their visa, breached their visa conditions and had their visa cancelled or have been refused entry at Australia's entry ports. There are centres located at: Villawood (established in Sydney in 1976); Maribyrnong (established in Melbourne in 1966); Perth (established in 1981); Christmas Island (established in 2001); Northern (established in Darwin in 2001). Revenue Unit Revenue Unit edia/factsheets/82detention.htm#i Immigration Detention Programs Immigration Residential Housing The department uses a number of programs which provide flexibility in the provision of services to people in immigration detention. These arrangements include community detention facilitated by organisations such as the Red Cross, detention in immigration residential housing or immigration transit accommodation and foster care arrangements (for unaccompanied minors). Immigration residential housing is a less institutional, more domestic and independent environment for low flight and security risk people in detention, particularly families with children. Participation in immigration residential housing accommodation is voluntary, subject to meeting eligibility criteria. edia/factsheets/82detention.htm#i edia/factsheets/82detention.htm#i Version No.: 1.0; Effective From: 1 July 2012 Page 13 of 19

14 Term Definition / Explanation / Details Source Immigration Transit Accommodation Immigration transit accommodation has been introduced for short-term, low flight risk people. Immigration transit accommodation offers hostel-style accommodation, with central dining areas and semiindependent living. Immigration transit accommodation provides a narrower range of services at a less intensive level than is typically offered in an immigration detention centre because of the short-stay nature of the client group. edia/factsheets/82detention.htm#i Journey Claim Medically necessary treatment under (RHCA) Medical services covered under the RHCA Medicare Eligibility Where the worker is injured on a journey between their home and place of employment, they are entitled to compensation for their injuries. This may include if the worker: was injured while on a journey between their home or workplace and a place of trade or training, which the worker was required to do as part of their work; have an existing Workers Compensation claim, which required them to go from their home or workplace to a place of medical or rehabilitation treatment when they experienced an accident that caused further injury; were travelling between employment with one employer and employment with another. The Workers Compensation and Rehabilitation Act 2003 states that the worker needs to have started the journey without any significant delays or deviations. If an injury occurs within the worker s home or boundary of their home, they have not begun their journey and therefore will not be entitled to compensation. Medically necessary treatment means any ill-health or injury which occurs while the person is in Australia and requires treatment before returning home. Free treatment as a public in-patient or out-patient in a public hospital Subsidised medicine under the Pharmaceutical Benefits Scheme (PBS). People who reside in Australia excluding Norfolk Island are eligible if they: hold Australian citizenship have been issued with a permanent visa hold New Zealand citizenship have applied for permanent visa (excludes an application for a parent visa) other requirements apply. com.au/rehab-andclaims/injuries-at-work See Workers Compensation and Rehabilitation Act 2003 for more details. alia.gov.au/ alia.gov.au/ alia.gov.au/public/register /eligibility.jsp Version No.: 1.0; Effective From: 1 July 2012 Page 14 of 19

15 Term Definition / Explanation / Details Source Motor Accident Insurance Commission (MAIC) Annual Grant (4) The amounts received into the fund by way of the Hospital And Emergency Services Levy are to be applied towards providing public hospital services and public emergency services and, for that purpose, are to be paid to relevant departments. (5) The Treasurer may decide at which periodic intervals, and in what proportions, the amounts are to be paid. (6) The Treasurer may advance amounts to the fund on the terms the Treasurer considers appropriate. Motor Accident Insurance Act 1994 Section 29 MAIC Claim MAIC Claims occur where the driver at fault was driving a motor vehicle registered in Queensland. The nonfault driver, passengers and pedestrians involved in accident can claim under Queensland compulsory third party scheme and their Queensland Health care is covered under the MAIC Annual Grant. Revenue Unit Motor Accident Insurance Commission (MAIC) Grant Motor Other Vehicle (3) The statutory insurance scheme levy is to cover the estimated costs of the administration of this Act (other than costs associated with the Nominal Defendant scheme) for the financial year for which the levy is fixed together with any shortfall from previous financial years. (4) The hospital and emergency services levy is to cover a reasonable proportion of the estimated cost of providing public hospital services and emergency services for the financial year for which the levy is fixed having regard to the number of people who (a) are injured in motor vehicle accidents; and (b) make use of public hospital services and emergency services as a result of their injuries; and (c) are claimants or potential claimants under the statutory insurance scheme. (5) The Nominal Defendant levy is to cover the estimated costs of the Nominal Defendant scheme for the financial year or other period for which the levy is fixed together with any shortfall from previous financial years. These patients are persons (non-fault driver, passengers and pedestrians) who are admitted to hospital from accidents where fault lies with the driver of a motor vehicle registered in a State or Territory other than Queensland. Motor Accident Insurance Act 1994 Section 12 Revenue Unit Version No.: 1.0; Effective From: 1 July 2012 Page 15 of 19

16 Term Definition / Explanation / Details Source Motor Vehicle Queensland These patients are persons (non-fault driver, passengers and pedestrians) who are admitted to hospital from accidents where fault lies with the driver of a Queensland registered motor vehicle. Revenue Unit Non-Clinical Extras Non-clinical extras are a range of products provided free of charge when the patient elects to be treated as a private patient such as: TV rental; Newspapers; Car parking for spouse/partner/parent; Meals for spouse/partner/parent; Local phone calls or toiletry kits. Revenue Unit Patient Election Form (PEF) In accordance with the National Healthcare Agreement, public hospitals admitted patient election processes for eligible persons should conform to national standards as documented in Appendix C of the agreement. National Health Reform Agreement Patient Liaison (POLE) Option Employee Patient Option Liaison Employee (previously known as Patient Option Liaison Officer (POLO)) is also called Patient Election Liaison Employee (PELE) by some facilities. POLEs are engaged to assist the patient with understanding the financial implications of their choice to be treated as a private or public patient. Revenue Unit Personal Injury Personal injury includes (a) fatal injury; and (b) pre-natal injury; and (c) psychological or psychiatric injury; and (d) disease Civil Liability Act 2003 (Qld) Personal Claim Injury Means a claim, however described, for damages based on a liability for personal injury, damage to property or economic loss, whether that liability is based in tort or contract or in or on another form of action, including breach of statutory duty and for a fatal injury including claims on behalf of the deceased s dependants or estate. Civil Liability Act 2003 (Qld) For the purpose of Queensland Health, these claims include the following: Public liability; Product liability; Motor Vehicle Other. Revenue Unit, Queensland Health But exclude: WorkCover Queensland; Motor Vehicle Accident Queensland (MAIC). Version No.: 1.0; Effective From: 1 July 2012 Page 16 of 19

17 Term Definition / Explanation / Details Source Product Liability Provisions of the Competition and Consumer Act 2010 (C wth) allow persons who suffer injury or loss as the result of a defective product to take legal action for compensation against the supplier of that product. Competition and Consumer Act 2010 (C wth) Public Liability This covers a wide range of circumstances where a person suffers injury or death as a result of another person s negligence or failure to take reasonable amount of care and may include the following public liability claims but not limited to: Slips or falls School accidents Recreational and sporting accidents Food poisoning Animal attacks Revenue Unit Recess Claim A worker may have an entitlement to Workers Compensation if they are injured while temporarily away from their place of employment during an ordinary recess period like a lunch break. m.au/home/glossary Reciprocal Health Care Agreement (RHCA) Right of Private Practice (RoPP) Visitors from RHCA countries are entitled to medically necessary treatment while they are in Australia, comprising of public hospital care (as public patients), Medicare benefits and drugs under the Pharmaceutical Benefits Scheme (PBS). Visitors must enrol with Medicare Australia to receive benefits. A passport is sufficient for public hospital care and PBS drugs. The entitlement to access Medicare benefits in accordance with the Health Insurance Act 1973 (Cwlth) to provide medical services to private patients in a public hospital. Policy B48: Right of Private Practice - Specialist Medical Officers Single Room A single room is a suitable room in a hospital which is purpose built and holds a single bed, licensed or approved by the State, for a single admitted patient. This room would have facility for no more than a single admitted patient (including nursing and other professional staff). This room can be allocated based upon the request of the private patient or on the basis of clinical need. G24(b) last sentence "Any patient who requests and receives single room accommodation must be admitted as a private patient (note: eligible veterans are subject to a separate agreement). Commonwealth Dept of Health and Aged Care April 2000, Circular HBE628 PH nternet/main/publishing.n sf/content/healthprivatehealth-providerscirculars _380.htm/$FILE/628_ 380.pdf National Health Reform Agreement Version No.: 1.0; Effective From: 1 July 2012 Page 17 of 19

18 Term Definition / Explanation / Details Source Subsidiary system Any system subordinate or secondary to FAMMIS in relation to debt management and accounting. This would include HBCIS utilising the Journal Module, manual systems, etc. Third Party Patients Waiver Third Party patient means a patient who (a) receives care and treatment for an injury, illness or disease; and (b) receives, or establishes a right to receive, an amount of compensation or damages for the injury, illness or disease. Under the Medicare Benefit Schedule and the National Healthcare Agreement, a Third Party patient is excluded from eligibility for Medicare. The National Healthcare Agreement states that Third Party (compensable) patients may be charged an amount for public hospital services as determined by Queensland. Charges are raised by Health Service Districts in accordance with the Health Services Regulation 2002 (Qld). Workers Compensation and Motor Accident Insurance Commission (MAIC) patients who have a public status are Third Party patients, but excluded from this policy as monies are recovered under different processes. MAIC patients, who choose to be treated as a private patient, must have prior approval from their CTP insurer. The patient would not be covered under the grant arrangements between MAIC and Queensland Health and their admission would be treated as Third Party Private/Shared. Waiver of fees (in part or in full) is clearly defined in the Health Services Regulation 2002 as available in respect of only nursing home type patient (S7(6)), residential care facilities (S14) and extended treatment facilities (S19) in the limited circumstances of financial hardship. Health Services Regulation 2002 (Qld) Schedule 3 Medical Benefit Schedule National Agreement Healthcare Revenue Unit Version No.: 1.0; Effective From: 1 July 2012 Page 18 of 19

19 Term Definition / Explanation / Details Source Workers Compensation Injury An injury as defined by the Workers Compensation and Rehabilitation Act 2003 is a personal injury arising out of, or in the course of, employment if the employment is a significant contributing factor to the injury. Injuries can happen at work, travelling to and from work or while on a break from work. Injuries can also take place if you are travelling for work, or visiting other workplaces or sites for the purposes of your job. Examples of different types of injuries covered: Physical injuries such as lacerations, fractures, burns, industrial deafness Psychiatric or psychological disorders such as stress or depression Diseases such as asbestosis or Q-fever Aggravation of a pre-existing condition Death from an injury or disease. Employees may be covered while working from home, as long as the injuries arise out of or in the course of employment, and the employment is a significant contributing factor to the injury. m.au/home/glossary com.au/rehab-andclaims/injuries-at-work 6. Guideline Revision and Approval History Version No. Modified by Amendments authorised by Approved by 1.0 Harley Trotman Version No.: 1.0; Effective From: 1 July 2012 Page 19 of 19