AMA Submission to proposed PHMAC Clinical Definitions – Not Good Enough

10 May 2018

The AMA recently lodged a submission to the Private Health Ministerial Advisory Committee (PHMAC) Secretariat’s consultation on mapping of MBS items to the proposed clinical definitions under the newly proposed Gold, Silver, Bronze and Basic private health insurance categories. The submission can be found here.

In the submission, the AMA expressed deep disappointment in relation to the consultation timeframe - less than three weeks, and limited to a selected group of stakeholders. The AMA highlighted that the mapping of MBS items appeared to be done independently of the relevant Department of Health Divisions, including Medical Benefits, Provider Benefits Integrity (Compliance) and the MBS Review.

The allocation of MBS items to clinical definitions ultimately determines the value proposition of private health insurance, when a patient is covered for a service, and when a benefit will be received. Therefore a siloed approach to the clinical definition work risks undermining both the work of the MBS Review - which examines MBS service application - and the PHMAC reforms, which aim to make private health insurance simpler for consumers.

In the short consultation timeframe permitted, the AMA was able to identify gaps in the proposed mapping that would ultimately result in PHI consumers experiencing an unexpected lack of coverage and out of pocket costs.

The AMA does not endorse the clinical definitions in their current form and has strongly advised the PHMAC Secretariat that more work is needed before the definitions are finalised.

The PHMAC was established in 2016 to examine all aspects of private health insurance and provide Government with advice on reforms including:

  • developing easy-to-understand categories of health insurance
  • developing standard definitions for medical procedures across all insurers for greater transparency and simplifying billing
  • ensuring private health insurance meets the specific needs of Australians living in rural and remote Australia.

For more information on PHMAC, visit the Department of Health’s website.

PHMAC’s Issues Paper: Gold, Silver, Bronze, Basic Implementation can be found here.