Types of hospital procedures
The Private Health Insurance (Benefits Requirements) Rules 2011 set out the minimum default accommodation benefits that private health insurers need to pay for hospital treatment. These depend on the MBS items for the procedure performed or services provided.
The rules define these procedures by grouping MBS items into:
- Type A procedures – usually done in hospital, with part of an overnight stay (higher accommodation benefits)
- Type B procedures – usually done in hospital, without part of an overnight stay (lower accommodation benefits)
- Type C procedures – don’t normally need hospital treatment or accommodation (no accommodation benefits).
If the medical practitioner certifies that the patient requires hospital treatment, health insurers can pay higher hospital accommodation benefits for Type B and C procedures.
The requirements for certification are set out in Schedule 1 Part 3 Sections 10 and 11 and Schedule 3 Part 2 Section 7 of the Benefit Requirements Rules.
While there is no specified format for the certification documentation it should include at a minimum:
- sufficient information to identify the patient, the certifying medical practitioner and the specific medical procedure being certified;
- details of the patient’s medical condition, or the special circumstances relevant to the specific procedure, that the medical practitioner is certifying require it to be performed in a hospital; and
- a signed statement with wording to the effect that the medical practitioner certifies that it would be contrary to accepted medical practice to provide the procedure unless the patient is given hospital treatment that either includes (if certifying as Type B) or does not include (if certifying as Type C) part of an overnight stay.
Hospital certification regulation
We are working on amendments to the Health Insurance Act 1973 that will both:
- encourage better certification processes for hospital admission by medical practitioners and hospitals
- expand the authority and functions of the Professional Services Review when certifying that Type C treatments or procedures must take place in hospital.
We will also encourage medical colleges, in consultation with other stakeholders, to develop guidance on when hospitalisation is appropriate. This will help medical practitioners understand accepted medical practice in Australia.
These guidelines will:
- provide transparency and accountability for clinical decisions
- reduce inappropriate practices
- not limit a medical practitioner’s clinical autonomy.
More information
Our July 2017 circular will help you understand how to apply the rules and avoid potential disputes.
Read the fact sheet on Hospital certification for MBS items for repetitive transcranial magnetic stimulation (rTMS)
More information about procedure types is available in our December 2020 consultation paper.
Also read our budget fact sheet on improving affordability and sustainability of private health insurance.