The issue of pre-approvals

In recent months a number of private health insurers have been engaging in activity that interferes with the doctor-patient relationship and hinders access to services for patients.

The Australian Society of Ophthalmologists (ASO) is not happy about this.

What we are seeing is big name insurers Medibank Private, Bupa and AHM asking doctors, including ophthalmologists, to sign pre-approval forms for MBS listed surgeries BEFORE they will agree to uphold cover for these surgeries for their member; cover that their members have paid for.

•Pre-approvals directly interfere with the doctor patient relationship.

•Pre-approvals are negatively impacting patient care.

•Pre-approvals are a step towards US-style managed care.

Signed pre-approvals being sought for procedures which correct eyelid abnormalities. These surgeries could be to ensure the correct development of vision in children or to correct vision after a deadly skin cancer has been removed.

Specifically these are MBS item numbers 45617, 45623, 45624 and 42590.

Contrary to the Act

In December 2015 the ASO received confirmation from the Federal Health Department that a private health insurer seeking to obtain signed pre-approvals for MBS listed procedures is contrary to the Private Health Insurance Act.

The Department provided the following advice to the ASO.

The Private Health Insurance Act 2007 requires private health insurers to pay benefits for hospital treatment when a member undergoes a procedure, which is covered by their complying health insurance product (CHIP) and a Medicare benefit is payable. 

This requirement is set out under section 72-1(1)(a) of the Act and states that an insurance policy that covers hospital treatment meets the benefit requirement rules in Division 72 if the policy meets the requirements in the table in subsection (2). The table in section 72-1(2) of the Act states in item 2 that there must be a benefit for hospital treatment covered under the CHIP for which a Medicare benefit is payable.

Therefore, if a member of a fund is insured for a certain treatment under a CHIP, and receives hospital treatment that includes a procedure for which a Medicare benefit is payable and paid for that treatment, it is the Department’s view that the fund must pay the benefit linked to that procedure. Any patient that is denied a private health insurance reimbursement that meets the provisions of the Act should contact the private health insurance ombudsman.

Cosmetic services and the MBS

By definition, no cosmetic services are covered by the MBS. It is a pre-requisite for the use of MBS item numbers, and the claiming of Medicare and Health Fund benefits for such services, that a surgery be non-cosmetic in nature.

Doctors say don’t ‘manage’ our patient's care

Managed Care, a term widely connected with the great failures of the US health system, takes control and choice away from patients.

It puts healthcare decision-making in the hands of big health insurance companies for whom the main agenda is increasing profit via a reduction in outlays.

Professor Emeritus Noam Chomsky, identifies the American healthcare system is about twice the per capita cost of comparable countries and has some of the worst outcomes. The reason, he says, is straightforward. It is privatised, it is very inefficient. There is a huge bureaucracy. And companies are interested in profit, not health (The Wire, 2016).

Australia has one of the best healthcare systems in the world. We must protect this system now to safegaurd against US style managed care.

The ASO warns...

Corporate goals of private health insurers aimed at ensuring greater returns for shareholders and reducing insurance outlays WILL result in a conflict of interest. These goals focus heavily on locking out competition as opposed to safeguarding the provision of quality health care.

We’re fighting this

It is unacceptable to require specialists to sign any pre-approval or Specialist Eligibility Form for non-cosmetic surgery or to involve third parties in assessment of such patients where a qualified specialist has deemed surgery clinically necessary. 

The ASO has established a strong dialogue with the Federal Health Department on this issue. We are keeping the government up to date on all activities by health insurers which spark concern.

For more information and advice on the issue of pre-approvals please call us on

07 3831 3006.