Health Fund Eligibility
By: Charles Wurf, CEO ATMS
A key business aspect of establishing yourself in practice is your eligibility to be recognised as a service provider with health funds. This is an important part of a practice strategy – what is the pricing strategy for services and what is the positioning strategy for health fund rebates. In this blog we guide you to understanding the provider eligibility requirements of the Australian health funds.
Australian Health Funds and ATMS
ATMS is a ‘professional organisation’ within the meaning of section 10 of the Private Health Insurance Accreditation Rules 2011. This is the enabling mechanism that allows ATMS Accredited members to be recognised as providers by the various private health funds.
Recognised provider status is subject to the specific rules and eligibility requirements of each individual health fund. Each health fund sets the rules for which modality it will cover. Each fund then also sets the eligibility requirements for the modality and what level of health insurance rebate is available for a service from a recognised provider.
ATMS Accredited membership does not automatically guarantee recognised provider status with health funds. ATMS can advise on the individual rules for each fund, and can assess education qualifications for eligibility. Once eligible, ATMS informs the health fund and the health fund issues formal recognition and any relevant provider numbers.
Attaining the status of a recognised provider with health funds is a valuable commercial asset for a natural medicine practitioner.
Provider eligibility requirements
To be eligible for health fund provider status, an Accredited Member of ATMS must meet the following general criteria:
• Be in private practice.
Note: ATMS and the Health Funds define Private Practice as follows:
‘Independent private practice means a professional practice (whether sole, partnership or group) that is self-supporting. This means that its accommodation, facilities and services are not provided or subsidised by another party such as a public hospital or publicly funded facility.
• Have a clinic address (mobile services must have an invoice address and Full street address, no PO Box addresses are accepted).
• Hold accreditation with ATMS in the relevant modality.
• Meet the health fund provider eligibility requirements for that modality, which may differ between funds.
• Have current Provide First Aid on file with ATMS at all times.
Note: To maintain a current certificate, an Accredited Member must ensure that there is no break or gap in cover, and that the Provide First Aid (or equivalent) certificate is continuous for all periods.
• Have current Professional Indemnity Insurance on file with ATMS at all times.
Note: To maintain a current policy, an Accredited Member must ensure that there is no break or gap in cover, and that policy coverage is continuous for all periods.
• Comply with the ATMS Continuing Professional Education (CPE) Policy.
The eligibility requirements for individual modalities are specific to each health fund. ATMS maintains detailed resources regarding these eligibility requirements, and these resources are available on the ATMS website at the following link: Click Here
Maintaining health fund recognition
The status of a recognised provider with health funds is a valuable commercial asset for a natural medicine practitioner.
Maintaining this valuable commercial asset requires 4 simple requirements to be completed each year:
1. Maintain Accredited membership with ATMS each year.
2. Maintain a current First Aid Certificate (and ensure that there is no break in continuous coverage for first aid).
3. Maintain a current professional indemnity insurance policy (and ensure that there is no break in cover and that it meets the minimum policy value required).
4. Complete Continuing Professional Education (CPE) to the equivalent of 20 CPE points per annum (and ensure that evidence of CPE activity is kept in your personal professional records).
Compliance and Audit for health fund recognition
An essential aspect to maintaining professional standing is ensuring compliance. Compliance for modern professionals is both pervasive and obligatory!
To ensure ATMS Accredited membership can be relied upon for professional standing, ATMS conducts the following compliance regime with Accredited members:
1. ATMS Membership covers each financial year from July to June, with unfinancial members removed from the membership register at the end of each renewal cycle.
2. ATMS maintains individual records for each member for First Aid compliance.
3. ATMS maintains individual records for each member for professional indemnity insurance cover.
4. ATMS conducts an annual compliance audit for CPE, covering a random sample of 5% of ATMS members.
In turn, ATMS is itself subject to audit by health funds to ensure that ATMS is correctly adhering to the health fund requirements for recognition and eligibility.
All compliance activity is grounded in maintaining the integrity of the professionalism of natural medicine practitioners who are ATMS Accredited members and who have recognised status with Australian health funds.