Medicare Benefits Schedule - Note IN.0.10

Part IIBA of the Health Insurance Act 1973 contains a number of provisions prohibiting inducements to request diagnostic imaging (and pathology) services.

Who might be affected?

­Anyone who can provide or request a Medicare-funded diagnostic imaging service.

­Anyone who has a relevant connection to a provider or a requester, including relatives, bodies corporate, trusts, partnerships and employees may also be affected. 

What is prohibited?

-          it is unlawful to ask for, accept, offer or provide a benefit, or make a threat, that is reasonably likely to induce a requester to make diagnostic imaging requests, or is related to the business of providing diagnostic imaging services.

-          it is a criminal offence to ask for, accept, offer, or provide a benefit, or make a threat that is intended to induce requests to a particular provider.

-          the prohibitions apply to the provision of benefits, or the making of threats, that are directed to a requester by a provider, whether directly or through another person. 

A requester of diagnostic imaging services means:

-          a medical practitioner;

-          a dental practitioner, a chiropractor, a physiotherapist, a podiatrist or an osteopath (in relation to certain types of services prescribed in Regulations);

-          a person who employs, or engages under a contract for services, one of the people mentioned above; or

-          a person who exercises control or direction over one of the people mentioned above (in his or her professional capacity). 

A provider of a diagnostic imaging service means:

-          a person who renders that kind of service;

-          a person who carries on a business of rendering that kind of service;

-          a person who employs, or engages under a contract for services, one of the people detailed above; or

-          a person who exercises control or direction over a person who renders that kind of service or a person who carries on a business of rendering that kind of service. 

What is permitted?

Under the Act it is permitted to:

-          share the profits of a diagnostic imaging business, provided the dividend is in proportion to the beneficiary's interest in the business;

-          accept or pay remuneration, including salary, wages, commission, provided the remuneration is not substantially different from the usual remuneration paid to people engaged in similar employment;

-          make or accept payments for property, goods or services, provided the amount paid is not substantially different from the market value of the property, goods or services;

-          make or accept payments for shared property, goods or services, provided the amount paid is proportionate to the person's  share of the cost of the property, goods or services and shared staff and/or equipment are not used to provide diagnostic imaging services;

-          provide or accept property, goods or services, provided the benefit exchanged is not substantially different from the market value of the property, goods or services;

-          provide benefits of a type determined by the Minister. These include items to support a requester to view diagnostic imaging reports, such as specially designed computer monitors.  Modest gifts and hospitality may also be permitted, under certain circumstances. A full list of the Ministerial determined permitted benefits are contained in the Health Insurance (Permitted benefits — diagnostic imaging services) Determination 2018.

What are the penalties for those not complying with the provisions?

If the provisions are breached, a range of penalties would apply, depending on the kind of breach, including: civil penalties; criminal offences; referral to a Medicare Participation Review Committee (MPRC), possibly resulting in loss of access to Medicare.   For further information on prohibited practices visit the Department of Health and Aged Care’s publication ‘Guidance on Laws Relating to Pathology and Diagnostic Imaging - Prohibited Practices’.

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