A: For patients treated in a public setting, your employer typically provides indemnity. We suggest you ensure that you are employer indemnified for any public work as this is not usually covered by your medical indemnity policy which is mainly for private practice. If you do not have cover from your employer for your public work, please contact us so that this cover can be arranged.

A: You should only provide healthcare you are appropriately qualified and trained to do. Ahpra has provided the following information about medical practitioners being fast tracked into new roles in responding to the Covid-19 crisis.

We are being asked a range of questions about how the National Boards would respond to requests for changes to the way that we register individuals in the context of managing the health sector impacts of COVID-19.

As an overriding principle, the National Boards and Ahpra are prepared to be flexible in our approach although safety remains our first priority.

In this context, we are considering how our regulatory requirements can adapt to emergency health service needs and support health service delivery while continuing to protect the public.

Avant will continue to rely on and recognise the regulators’ assessments of appropriate qualification to act. To ensure you are covered you should only provide healthcare where you are qualified and maintain your insurance coverage.

You should maintain coverage with us that is appropriate for your practice and, if you are considering changing your area of practice, please check if your existing category or practice includes the new work you are undertaking.

If you are still unsure or need to change category, please contact us on 1800 128 268.

A: Generally, the treatment of a public patient is state indemnified. Currently there is not a clear position on how the state insurer indemnity will operate for public patients in a private facility. Avant wants you to be able to practice with confidence and can confirm your current policy will cover you for healthcare provided to all patients in private hospitals where you are not indemnified by the state, the hospital or another insurer, provided you declare your private billings for this work.

Coverage is subject to the terms and conditions of the policy.

A: Medical indemnity insurance premiums are based on several factors. Your annualised billings is one of these factors. If these have changed significantly from what is noted in your current policy documents, we can amend them which could reduce your premium. Please call us on 1800 128 268 to discuss possible changes.

A: Yes. However, if you have stopped all practice of medicine, you may be eligible to change your category of practice to Absentee. This category continues to provide you with cover for claims against you that relate to your prior medical practice but does not provide cover for any current healthcare that you provide. The premium for Absentee cover is $200 for any period up to 12 months. You should only consider changing your policy to Absentee if you plan to stop all medical practice. You will need to notify us prior to returning to your practice to arrange appropriate cover.

A: Avant is offering a range of options on indemnity policy premiums, to members whose incomes have been impacted due to COVID-19. Each member will have their own unique circumstances and we are offering solutions that best meet individual needs, which can include:

✓ Premium adjustments for reduced billings for eligible members

✓ Transfer to an Absentee category for eligible members unable to practice with medical indemnity premiums waived until practice resumes

✓ A range of installment options, including monthly payment options

For members or practices who are experiencing significant financial hardship and are not able to meet payments, Avant may be able to assist you.

Please contact us on 1800 128 268 to discuss how we can support you.

A: Yes. Your practitioner policy covers you for this. However, it is important that you take precautions and follow all available advice to ensure that you can prevent transmission where possible. There is no cover under your policy if you know, or should have reasonably known or suspected, that you had the virus and then transmitted it to a patient. Therefore, if you are aware that you are infected, or suspect that you might be, it is important that you cease practising immediately and inform your hospital/local health service immediately.

A: The Medical Board of Australia and other National Boards are working with AHPRA to streamline the return to work process for practitioners who have been off the Register of practitioners, or who have held non-practising registration since 1 January 2017. Details of their current advice are available on the AHPRA website.

In addition to registration you will also need medical indemnity insurance if you are practising privately. Avant will be able to arrange insurance cover for doctors returning to practice.

Avant is pleased to support non-practising or retired doctors who may be considering returning to medical practice to assist with the crisis, by providing medical indemnity cover at no cost during the COVID-19 emergency period. To express your interest, please complete this application form and then email to applications@avant.org,au for more information.

On 31 March 2020, regulations were passed to provide certainty for doctors who return to practice and currently hold run-off cover. Importantly, doctors will not need to arrange cover for prior practice and the regulations provide an exemption for doctors to maintain their cover through the Run-Off Cover Scheme while returning to practice for the period of the COVID-19 crisis.

A: Telehealth activities are covered under your practitioner policy. This includes consultations conducted via video conference and telephone, as well as SMS. You are covered anywhere in Australia.

Where there is a pre-existing clinical relationship with your patient, you are covered for telehealth activities where you are outside of Australia (for less than 120 days) and the patient is in Australia, or where the patient is outside of Australia (for less than 90 days) and you are in Australia (please refer to the policy wording for all details).

A: You are covered under your practitioner policy for defending complaints in relation to breaches of workplace health and safety laws, as well as any fines and penalties as a result.

A: Yes. If you are an Avant member and a doctor in training, you are covered for the healthcare you provide in private practice where:

• it forms part of your training program; or
• it falls outside your training program, but it is consistent with your qualifications and experience.

You are also covered for volunteer work that is consistent with your qualifications and experience.

Cover is subject to the full terms, conditions and exclusions of the Avant practitioner policy.

If you are employed by a hospital/or health service, you will generally be indemnified by your employer for the work that you do, including for compensation claims.

However, not all employers cover the expenses for legal advice and representation for employment disputes, training disputes and coronial matters, amongst other things. It is important that you know whether you have the cover that you need through your employer. If you would like to find out more, please contact Avant Member Services on 1800 128 268.

A: Yes. Generally, you will be covered by your employer under your employment contract for treating patients in a private setting. However, if your employer does not provide you with this cover then your Avant practitioner policy will be able to provide this cover without you having to make any changes to your policy. If you need to update your category of practice e.g. if you move from a GP registrar to a hospital registrar, please contact us. Cover is subject to the full terms, conditions and exclusions of the Avant practitioner policy.

A: Yes. Your practice policy provides cover for claims for compensation made against the practice which relate to the healthcare services you provide. Legal fees and expenses for disciplinary matters (e.g. tribunal or registration board) are also covered under your practice policy.

A: The Australian Government has enacted a further significant change to the telehealth items introduced on 13 March 2020 in response to the COVID-19 pandemic. These changes only apply to GPs and other medical practitioners working in general practice. They do not apply to specialists and other healthcare providers. Telehealth items that were available prior to COVID-19 also remain unaffected by these changes and can continue to be billed where appropriate.

From 20 July 2020, it is a legislative requirement under the Health Insurance (Section 3C General Medical Services - COVID-19 Telehealth and Telephone Attendances) Determination 2020 that GPs and other medical practitioners working in general practice only perform a telehealth or telephone service where they have an existing relationship with the patient, in order to bill the consultation to Medicare under this Determination. Private billing arrangements can still be made for telehealth consultations with appropriate informed financial consent.

An existing relationship with a patient is defined as:

• The medical practitioner who performs the service has provided a “personal attendance” or face-to-face service to the patient in the last 12 months. The Determination does not specify where the personal attendance has to occur, so in our view this may be either in the medical practice, aged care facility or at a home visit; or
• The medical practitioner who performs the service is located at a medical practice, and the patient has had a face-to-face service arranged by that practice in the last 12 months. This can be a service performed by another doctor located at the practice, or a service performed by another health professional located at the practice (such as a practice nurse or Aboriginal and Torres Strait Islander health worker); or
• The medical practitioner who performs the service is a participant in the Approved Medical Deputising Service (AMDS) program, and the Approved Medical Deputising Service provider (AMDS provider) that engages the medical practitioner has a formal agreement with a medical practice that has provided at least one face-to-face service to the patient in the last 12 months.

The requirement to have had a face-to face consultation in the last 12 months does not apply to:

• children under the age of 12 months
• people experiencing homelessness (see below)
• people located in a COVID-19 impacted area (see below)
• people receiving an urgent after-hours service (in unsociable hours)
• people who receive the service from a medical practitioner located at an Aboriginal Medical Service or an Aboriginal Community Controlled Health Service.

A person is considered homeless if their current living arrangement:

(a) is in a dwelling that is inadequate; or
(b) has no tenure, or if their initial tenure is short and not extendable; or
(c) does not allow them to have control of, and access to space for social relations.

Telehealth consultations can still be conducted and billed to Medicare with a person who is in a “COVID-19 impacted area”. This means a patient who, at the time of accessing the telehealth service, has had their “… movement restricted within the State or Territory, by a State or Territory public health requirement applying to the patient’s location”. The Determination doesn’t specify what constitutes a “public health requirement”. We have clarified with the Department of Health that the exemption covers the areas subject to specific restrictions such as Melbourne and Mitchell Shire, but also exempts:

“Patients that test positive for COVID-19 and/or are subject to quarantine or other social restrictions on the basis State and Territory health authorities”.

This will potentially cover a range of patients who have had their movement restricted by state or territory public health orders or public health guidelines on self-isolation. Examples of this, based on the NSW and Victorian laws, are:

• People who live in Melbourne and the Mitchell Shire subject to restrictions on their movement.
• People diagnosed with COVID-19 who are subject to self-isolation orders such as the Public Health (COVID-19 Self-Isolation) Order (No 2) 2020 (NSW) under the Public Health Act 2010 (NSW) which directs that a person diagnosed with COVID-19 must self-isolate in their residence or other suitable location until medically cleared and comply with the COVID-19 self-isolation guidelines.
• People returning from overseas who are subject to quarantine orders such as the Public Health (COVID-19 Quarantine) Order 2020 (NSW).
• People travelling across borders within Australia who are also subject to local quarantine orders. Public Health (COVID-19 Border Control) Order 2020 (NSW) requires, for example, people from Victoria to self-isolate under certain circumstances when they arrive in NSW.

It is also likely to cover patients who have been required (by government or public health guidelines) to self-isolate pending test results or because they are suspect cases or close contacts of confirmed cases.

However, patients living in areas that are not restricted by government lockdown orders and who are not suspected of having COVID-19, will not be able to access telehealth services simply because of their fears of contracting COVID-19 in the community if they do not also fulfill the criteria of having had a personal attendance with the particular GP or that was arranged by the particular GP’s practice in the past 12 months.

If these issues are unclear, you may wish to document that you have given consideration as to whether a patient has had their movement restricted within a state or territory in the patient’s medical record.

Some common scenarios* include:

Q: I saw patient X at practice A 10 months ago. Can I provide a telehealth consultation (THC) for him from practice B?

A: Yes, as patient X has had a personal attendance with you in the past 12 months.

Q: Patient X attended practice A 10 months ago and saw another GP, but I wasn’t working at practice A at that time. Can I now provide patient X with a THC?

A: Yes, as patient X has had a personal attendance with a GP at practice A within the last 12 months.

Q: I have had regular THCs with patient X over the past four months since the pandemic started, developing a good clinical relationship, but I have not yet seen the patient in person and the patient has never attended my practice in person in the past. Can I continue to provide THCs?

A: No, patient X needs to see you in person before you can continue to provide and bill Medicare for any THCs. Alternatively, patient X will need to arrange a THC with a doctor at their former practice if they attended there in person within the last 12 months.

Q: I saw patient X in her home/nursing home in March but otherwise we have had THCs due to her vulnerability to COVID-19. Can I continue with the THCs?

A: Yes, you have had a personal attendance with patient X in the past 12 months.

Q: Patient X is a new patient. She is unwell and doesn’t want to come into the clinic for fear of contracting COVID-19 as her husband is immunocompromised. She doesn’t live in a ‘hotspot’. I am unable to do a home visit. Can I see her via a THC given her anxiety and medical condition?

A: These reasons do not fall within the exemptions listed in the Determination. The patient will need to come and see you face-to-face or attend the hospital or contact her old practice to see if they will do a THC if she can’t get in to see you. You have the option of doing a THC and privately billing the patient with informed financial consent.

*These scenarios are based on the assumption that the consultations are not covered by the telehealth items applicable to GPs prior to COVID-19.

Further information

• Health Insurance (Section 3C General Medical Services – COVID-19 Telehealth and Telephone GP Attendances) Amendment (Patient’s Usual Medical Practitioner) Determination 2020..
• MBS changes:
• factsheet on telehealth items
• factsheet for GPs
• RACGP website.

A: New MBS telehealth items were progressively introduced from 13 March 2020, with some items coming into effect from different dates. The new items are listed on the Department of Health website, and can be used until 30 September 2020.

It is a legislative requirement that the new telehealth services, where they are provided by GPs and Other Medical Practitioners (OMP), must be bulk-billed to:

(a) a person who is a patient at risk of COVID-19 virus; or
(b) a person who is a Commonwealth concession card holder; or
(c) a person who is under the age of 16.

A “patient at risk of COVID-19 virus” means a person who:

(a) is required to self-isolate or self-quarantine in accordance with guidance issued by the Australian Health Protection Principal Committee in relation to COVID-19; or
(b) is at least 70 years old; or
(c) if the person identifies as being of Aboriginal or Torres Strait Islander descent—is at least 50 years old; or
(d) is pregnant; or
(e) is the parent of a child aged under 12 months; or
(f) is being treated for a chronic health condition; or
(g) is immune compromised; or
(h) meets the current national triage protocol criteria for suspected COVID-19 infection.

The Department of Health has stated that health providers may apply their usual billing practices to the telehealth items for patients who do not fit the above criteria. Providers are expected to obtain informed financial consent from patients before providing the service; providing details regarding their fees, including any out-of-pocket costs.

This requirement does not apply to specialists or allied health service providers.

A: There are separate billing codes for specialists, physicians, psychiatrists, paediatricians, geriatricians, public health physicians, neurosurgeons and anaesthetists. The requirements are:

• you still need a referral from a GP (existing referrals remain valid)
• the patient must be an out-patient.

There are specific requirements depending on the item number used, so check each item number carefully and ensure your documentation supports your use of the particular item number.

From 20 April 2020, specialists and allied health service providers are no longer required to bulk-bill these new telehealth items.

A: Yes. You can provide services to your patients by telehealth or telephone as long as you have the capacity to provide “… the full service through this means safely and in accordance with professional standards”, and you are satisfied that it is clinically appropriate to provide the service to the patient.

A: The patient needs to consent to having a consultation by telephone or video conference. This consent can be obtained verbally at the time of the consultation and recorded in the medical records.

Because telephone consultations may only be used where telehealth (video) consultations are unavailable, you may need to communicate with the patient before the first telehealth medical consultation to establish whether or not the patient has the technology to participate in a video consultation.

The Department of Health has stated that health providers may apply their usual billing practices to the telehealth items for patients who do not fit the criteria for bulk-billing. Providers are expected to obtain informed financial consent from patients before providing the service; providing details regarding their fees, including any out-of-pocket costs.

The Australian College of Rural and Remote Medicine provides a helpful guide to outline the risks/benefits of telehealth for patients, with a consent form which can be completed if considered necessary, but this is not a legal requirement.

A: The advice from the Department of Health is that patients are still required to consent to their telehealth service being bulk-billed, as per normal practice for bulk-billed services.

Where practicable, each individual provider should make efforts to obtain a patient’s signature in whichever way is appropriate to their needs. There are several options available to providers performing these services:

• Provider to post the completed assignment of benefit form to the patient to obtain their signature and return.
• Request assistance from a supporting practitioner (when there is one and possible).
• Email agreement between the provider and patient.

However, the Department of Health’s position is that, under these exceptional and temporary circumstances, for the new temporary MBS telehealth items only, the practitioner’s documentation in the clinical notes of the patient’s agreement to assign their benefit as full payment for the service, would be sufficient.

This means that agreement can be obtained through one of three options being in writing, by email, or verbally through the technology with which the attendance is conducted.

This agreement can be provided by a patient, or another person, such as the person’s carer or family member. The practitioner should keep their own record that the patient agreed or acknowledged that the service was provided, and that the Medicare benefit could be paid directly to the practitioner.

The Department of Health has indicated that it may investigate potentially fraudulent claims by seeking to verify that the service was provided to a patient. However, the Department has stated that it is not intending to undertake compliance activity directly focused on whether the assignment of benefit process aligned with the usual requirements.

The General, Specialist and Diagnostic (assignment of benefit) form (DB4) is available through Medicare Bulk-Bill Webclaims using HPOS.

The Department of Health provides the following guidance for a patient to assign their right to a Medicare benefit to you by email.

For privacy reasons, the Department of Health advises that you should not include the patient’s Medicare card number or the doctor’s provider number in your email to the patient.

Step 1

At the telehealth consultation, tell the patient you wish to bulk-bill Medicare for the service. To do this the patient will need to:

• agree to the service being bulk-billed
• check the details in the email sent to their nominated email address
• reply to your email, which will be considered a signature agreeing to assign the benefit.

Step 2

Before submitting the claim, you need to send an email to the patient that includes all of the below:

• the details of the service
• item numbers or a description of the services
• benefit amount for both the base and derived fee items
• date and time of the services
• patient's name (don’t include the Medicare card number)
• practitioner's name (don’t include the provider number)

Include in your email this statement:

'If you (the patient) agree to the assignment of the Medicare benefit directly to the provider (bulk bill), reply to this email including the following words:

Yes, I agree to the assignment of the Medicare benefit directly to the provider, and your (the patient's) name'

and this privacy note:

'Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Your information may be used by the department or given to other parties where you have agreed to that, or where it is required or authorised by law (including for the purpose of research or conducting investigations). You can get more information about the way in which the department will manage your personal information, including its privacy policy.

Step 3

When you get a reply email from the patient with the required information:

• complete a General, Specialist and Diagnostic (assignment of benefit) Voucher form (DB4)
• for manually submitted claims write in the signature block ‘unable to sign, written email agreement provided’
• for electronic claims, you don’t need to note the email signature, but you must keep the patient's email consent on file
• submit the claim to us in accordance with the Health Insurance Act 1973, 1975 Health Insurance Regulations and MBS
• send a completed copy of the General, Specialist and Diagnostic (assignment of benefit) Voucher form (DB4) to the patient
• keep the email with the patient's consent and email signature, in hard copy or electronic form for audit purposes for at least two years.

By noting 'email agreement' on the manual General, Specialist and Diagnostic (assignment of benefit) form (DB4), you acknowledge you’ve followed steps 1-3 above. This process complies with section 10 of the Electronic Transactions Act 1999, which outlines the steps to be taken for an electronic signature to be recognised. It also meets the legal requirement of needing a patient signature to assign a Medicare benefit.

Example email

A: The Department of Health advises that you should use the provider number for your primary location.

A: Where the COVID-19 telehealth and telephone services are bulk-billed, no additional charge may be rendered for the service (regardless of how the charge is described).

From 20 April 2020 the options available to GPs/other medical practitioners and specialists for charging COVID-19 telehealth and telephone services differ.

GPs and other medical practitioners who render the temporary COVID-19 items must bulk bill certain patients:

(a) a person who is a patient at risk of COVID-19 virus; or
(b) a person who is a Commonwealth concession card holder; or
(c) a person who is under the age of 16.

In other cases, GPs and other medical practitioners are not required to bulk-bill the COVID-19 items and may render an additional charge subject to obtaining informed financial consent from the patient.

Specialists and allied health service providers, from 20 April 2020, are no longer required to bulk bill these new telehealth items even when rendered to the patient groups listed above. Where the COVID-19 services are not bulk-billed, an additional charge may be rendered subject to obtaining informed financial consent from the patient. If you choose to do this, you should inform patients that other practices may bulk-bill the service under the COVID-19 telehealth items so they are aware of their options.

A: Yes. Bulk-billing incentive items can be claimed with face-to-face attendances or with the new COVID-19 telehealth and telephone services, where the conditions of the bulk-billing incentives are met. From 20 April, there are two new bulk-billing incentives introduced for vulnerable patients (items 10981 and 10982). These bulk-billing incentives will be equivalent to 10990 (metropolitan/urban) and 10991 (regional).

Vulnerable means a patient at risk of COVID-19, so a person who:

• is required to self-isolate or self-quarantine in accordance with guidance issued by the Australian Health Protection Principal Committee in relation to COVID-19; or
• is at least 70 years old;
• if the person identifies as being of Aboriginal or Torres Strait Islander descent—is at least 50 years old; or
• is pregnant; or
• is the parent of a child aged under 12 months; or
• is being treated for a chronic health condition; or
• is immune compromised; or
• meets the current national triage protocol criteria for suspected COVID-19 infection

A chronic health condition is medical condition that has been present (or is likely to be present) for at least six months or is terminal. The Department of Health website provides additional detail about chronic conditions. The diagnosis of immune compromised is a clinical decision made by the patient’s treating doctor. Please note this is guidance only, and does not constitute MBS claiming advice.

For clarification, the new bulk-billing incentives cannot be claimed in addition to existing bulk-billing incentive items. So, for example, if a medical service is provided to a patient who is both a holder of a Commonwealth concession card and falls under the definition of a vulnerable patient because they are 75 years old, only one relevant bulk-billing incentive may be claimed. Similarly, if a medical service is provided to a patient who is both under 16 years old and falls under the definition of a vulnerable patient because they are pregnant, only one relevant bulk-billing incentive may be claimed.

A: Yes.

There are three ways you can bill your patients when using telehealth services:

1. Bulk-billing.
2. Private billing where the patient receives a Medicare rebate and pays an out of pocket amount.
3. Private billing outside the Medicare system.

For patients who are not entitled to be bulk-billed, you can bill patients in the usual way, but you need informed financial consent from your patients before providing the service. You should therefore provide your patients with:

• Details of your fees, including any out-of-pocket costs.
• Details of the amount of any Medicare rebate.

Some practices are choosing to privately bill patients outside the Medicare system, who may otherwise be entitled to be bulk-billed under the MBS COVID-19 telehealth item numbers. A doctor and patient can agree that there will be no Medicare benefit for the service (and the doctor will issue a receipt which cannot be used by the patient to claim a Medicare benefit). If you choose to do this, you should inform patients that other practices may bulk-bill the service under the COVID-19 telehealth items so they are aware of their options.

A: If you bill privately, patients need to know details of your fees, including any out of pocket expenses and what Medicare rebate, if any, they will receive.

Informed financial consent can be given verbally and documented in the medical records or confirmed in an email (see below for a suggested email agreement).

If you are privately billing the whole amount of your fees (for example because the patient is not Medicare-eligible, or you decide to privately bill outside the Medicare system) we suggest you indicate on your receipt issued to the patient that there is no Medicare benefit payable for the service.

You should also inform patients if they would be entitled to be bulk-billed under the COVID-19 telehealth items if they attended another practice.

Example Email Agreement – Privately Billed Telehealth Consultation

A: GPs and specialists/physicians/consultant psychiatrists can provide service via telephone or video consultations if the criteria are satisfied. Telephone consultations should only be used where audio-visual (telehealth) consultation is unavailable.

To claim ‘telehealth’ items, practitioners must have video conferencing. There are separate item numbers for video and telephone consultations.

The Department of Health has advised that for the new temporary obstetric telephone services provided under items 91855, 91856, 91857 and 91858, these services must not be performed in cases where the practitioner and patient have the capacity to undertake an attendance by video conference.

A: There is no particular platform that you must use for telehealth.

The Department of Health has confirmed that:

• For Medicare purposes, no specific equipment is required to provide Medicare-compliant telehealth services.
• Services can be provided through widely available video calling apps and software such as Zoom, Skype, FaceTime, Duo, GoToMeeting and others.
• If video is not available, you can offer audio-only services. There are separate items available for audio-only/telephone services. The Department of Health has noted that this would not include online chat box/messaging and email as there is no visual or audio link.
• Free versions of the video/audio applications (i.e. non-commercial versions) may not meet applicable laws for security and privacy.

Under privacy legislation you are required to take reasonable steps to protect the privacy and security of the information that you hold. This means that you need to satisfy yourself that the platform you choose has adequate security measures to ensure that your patients’ health information is protected.

The platform provider’s terms and conditions or specifications should include relevant information about privacy and security. Have a look for:

• Compliance with Australian privacy laws and the Australian Privacy Principles (APPs).
• Security features such as multi-factor authentication and encryption. The Australian Cyber Security Centre advises that web conferencing solutions that exclusively support Transport Layer Security version 1.2 and 1.3 inherently offer more protection for data transmitted across the internet.
• The ability to use password-protection and unique links/invitations to video conferences.
• Details about the information the service provider collects and where it keeps that information. Is the service provider (or its servers) based in Australia?

As well as commonly available platforms such as Skype, Zoom and FaceTime, there are several bespoke telehealth platforms, and many medical software companies are incorporating video conferencing within their practice software. There is further information about these platforms in the resources listed below. Your IT provider is also a good source of information.

When you are using telehealth, consider your own privacy and the privacy of your staff. Use a practice account and be mindful that if you use your personal mobile phone or computer, patients may be able to access your personal number and email address. Also ensure that you have sufficient security in place for your practice systems to reduce the risk of a privacy breach or cyber security incident. For more information see our Cyber security resources.

Resources

The Australian Cyber Security Centre

• Web Conferencing Security
• COVID-19: Cyber Security Tips When Working From Home

Hoxton MPM Telehealth Road Test: What platform is best for your practice? *
PULSE+ITTechnology resources for COVID-19
ACRRM eHealth and Technology Directory
RACP Telehealth resources
RACGP Telehealth
RANZCP position statement on telehealth in psychiatry

*Disclosure: Avant is affiliated with and has a shareholding in HMPM Pty Limited (Hoxton).

A: Some practices are already set up already for telehealth consultations with specialists. For those practices requiring guidance, the RACGP’s video consultation guidelines provide helpful information on getting started.

You need to consider what you need to do if you are conducting the consultation from the practice or from home. Some of these things are:

• How are you going to provide patients with the ability to contact you by phone or video conference?
• Do you have remote access to your medical records system from home? If you don’t have access, you will need to keep records that can be scanned into the system, including billing information. You also need to be mindful of the limitations of the advice you can provide without immediate access to the patient’s medical records.
• How will prescriptions and medications be provided to patients if they cannot visit the practice or pharmacy? Some of the options include getting consent for a family member to collect the prescription or sending them to a local pharmacy and arrange for delivery of the medications to the patients.
• Do you have a printer at home if you need to send a letter?

Telehealth and telephone consultations will be a new experience for many patients, so the RACGP recommends communicating with patients about the process and the benefits before they take part. A template patient brochure is available from the RACGP website.

A: It is a MBS requirement that you have the capacity to provide the full service through telehealth or telephone safely and in accordance with professional standards. The MBS telehealth item number descriptors also require general practitioners to undertake the following in each telehealth or telephone consultation:

• take an appropriate patient history
• arrange any necessary investigation
• implement a management plan;
• provide appropriate preventative healthcare;

Always be aware of the limits of what you can achieve via the phone or video link if you are unable, for example, to check a patient’s blood pressure or temperature (and they cannot reliably do this remotely).

You will need to consider whether a physical examination is necessary and have a plan in place for referral of the patient if you are in self-isolation. This may be to a colleague in your practice if they are available to see the patient, the local hospital if appropriate or to another practice in the area if your practice is closed or the doctors cannot see additional patients.

The Good medical practice code of conduct applies to telehealth consultations as it does for face-to-face consultations. Doctors providing care via any form of technology are also required to follow the Medical Board’s Guidelines for Technology-Based Patient Consultations.

What this means in practice is:

• you need to be able to verify the identity of the patient
• the usual principles apply for obtaining your patient’s informed consent and protecting their privacy
• you need to keep appropriate records of the consultation
• if providing prescriptions you need to have enough information about the patient’s past medical history and current medical conditions, and medications to satisfy yourself that the prescription is appropriate and not contra-indicated.

A: Workplace health and safety legislation in each state and Territory explains what matters are required to report to the regulator.

In Victoria, regulations commenced on 28 July 2020 requiring notification to WorkSafe if an employee, contractor or other worker received a confirmed diagnosis of COVID-19 and attended the workplace within the relevant infection period.

You can find further information on the WorkSafe Victoria website.

A: As a healthcare worker, you should not attend work if:

State and territory health departments are actively encouraging all employees not to attend work if they are sick in any way.

You cannot attend work during any period of self-isolation, but you can work from home (if possible).

You will need to follow local guidelines about when you can stop isolating and return to work if you are a confirmed or probable case of COVID-19.

The CDNA guidelines contain detailed and up to date information relevant to self-isolation, returning to work, and managing both negative and positive diagnoses.

Before returning to work after any period of isolation:

You should comply with any state or territory public health direction about leaving isolation and about requirements after leaving isolation.

We have set out the legal position below, but it is up to each practice to determine how best to manage the situations that arise with their staff. Many Australian employers are choosing to provide paid special leave to employees who are required to self-isolate.

Any worker who can work from home during a self-isolation period should do so and should continue to be paid as usual.

If a worker is not able to work from home (e.g., due to the nature of their role), the business will need to consider how to pay the worker, taking into account the legal position below.

1. The employee is sick

If the employee has contracted COVID-19 or is otherwise sick, the employee is entitled to paid sick leave. The employee can take other forms of paid leave if they run out of paid sick leave.

2. The employee is required to self-isolate due to government requirements

On 8 April 2020, the Fair Work Commission varied the following awards to include an entitlement to unpaid pandemic leave if an employee is required to self-isolate:

• Health Professionals and Support Services Award 2010
• Nurses Award 2010
• Aboriginal Community Controlled Health Services Award 2010
• Medical Practitioners Award 2020

The new clause (which is Schedule X to the above awards) operates from 8 April 2020 until further order of the Fair Work Commission.

On 29 July 2020, the Fair Work Commission further varied the following awards to include an entitlement to paid pandemic leave if an employee is engaged in the aged care industry and is required to self-isolate:

• Health Professionals and Support Services Award 2010
• Nurses Award 2010

The new clause (which is Schedule Y to the above awards) operates from 29 July 2020 until 29 October 2020.

3. The employee is required to self-isolate by the employer

Given the unique circumstances of COVID-19, a practice can require an employee to self-isolate if the practice is concerned that the employee may be a COVID-19 risk. However, the practice must pay the employee their usual wages for the relevant period without deduction from leave entitlements.

A: This will depend on where your practice is located.

Victoria: Face coverings were made mandatory for those living in the Melbourne and Mitchell Shire when outside the home from 22 July 2020. This was extended to all Victorians when outside the home from midnight on 2 August 2020. There are a number of exceptions to the requirement to use face coverings which you can read about here.

NSW: People in NSW should consider wearing a face mask in situations where physical distancing is not possible.

Other areas: The current expert advice is that masks are not required if reception staff are not likely to be in close contact with suspected or confirmed cases, and if measures such as physical distancing, standard precautions including hand hygiene, screens and triaging protocols, are implemented.

The advice about face coverings is rapidly evolving so it is important to check for the current advice in your state.

Work health and safety laws require medical practices to implement control measures to eliminate or minimise the spread of COVID-19 and ensure the health and safety of their workers, patients and others at the workplace. Each situation needs to be assessed to ensure reception is kept safe and protected. In areas of high community transmission, Safe Work Australia recommends that employers undertake a new risk assessment given the new risks that have arisen.

If staff themselves feel unwell, they should stay at home, let their supervisor know and seek further medical advice.

View our article on this topic.

A: The Office of the Australian Information Commissioner has stated that yes, you may inform staff that a colleague or visitor has or may have contracted COVID-19 but you should only use or disclose personal information that is reasonably necessary to prevent or manage COVID-19 in the workplace.

For example, depending on the circumstances, it may not be necessary to reveal the name of an individual in order to prevent or manage COVID-19, or the disclosure of the name of the individual may be restricted to a limited number of people on a ‘need-to-know basis’. Whether disclosure is necessary should be informed by advice from the Department of Health.

A: It has become a widely spread practice to test a person’s temperature before allowing the person access to premises (for example, employees, patients and customers).

You can only take a person’s temperature with their consent. If testing is used for screening for access to the practice, you should have a protocol about temperature testing which includes what will happen if a person’s temperature is above the required temperature or a person refuses to have their temperature taken. You should consider whether employees with a high temperature will be paid sick leave.

The current advice is that temperature testing may be appropriate in high risk settings such as medical practices but may not be appropriate in other settings. For example, see advice from the Department of Health, Safe Work Australia and Safe Work NSW.

In some states and territories, public health directions require temperature testing before entry into residential aged care facilities.

A: Read our article, 'Clarity on providing medical certificates during COVID-19’.

A: We have received calls from doctors who have been asked to write medical certificates for school students for a range of reasons, including that the student is a vulnerable person, the student lives with a vulnerable person or the student’s parents are concerned about the general risks of COVID-19.

In Australia, schooling is compulsory for children who are 6 to 17 years old unless an exemption applies (for example, leaving school at 15 to undertake an apprenticeship) or the parent has a reasonable excuse for the child’s non-attendance (as determined by the school’s principal).

A child’s parents have a legal obligation to ensure their child attends school and can be charged with an offence if the child does not.

It is generally a reasonable excuse for a child not to attend school if the child is sick or has to attend a medical appointment. A school principal can require medical certification to be satisfied that a reasonable excuse exists.

In states and territories where Australian schools have fully re-opened, school attendance is expected unless the child has a reasonable excuse.

It is important to consider the current medical evidence before writing a medical certificate for a child.

If you are asked to write a medical certificate, you will need to consider whether the child is unfit to attend school due to a medical condition or at a greater risk of contracting COVID-19 or becoming very ill from COVID-19 as a result of their medical condition, or whether the child is likely to transmit COVID-19 to a vulnerable family member.

For more information see NSW Health and Don’t Forget the Bubbles.

A: On 22 May 2020, the Australian Health Protection Principal Committee (AHPPC) advised that levels of elective surgery activity could increase in an incremental and cautious way, while maintaining necessary ICU capacity for any localised outbreaks of COVID-19.

On 28 July 2020, in view of the increasing number of COVID-19 cases, the Victorian Government announced the following changes to elective surgery in Melbourne and the Mitchell Shire:

• All non-urgent Category 2 elective surgery across public and private hospitals in metropolitan Melbourne is paused.
• Surgeries that have already been booked will proceed.
• Only new Category 1 and the most urgent Category 2 surgeries will be booked for future surgery.
• IVF treatments such as egg retrievals will be able to continue given the time critical nature of these procedures and minimal impact on hospital capacity.
• All category 3 surgery remains paused, as announced on 16 July.
• There will be no changes to elective surgery in regional Victoria, but regional cases will continue to be monitored to ensure hospitals have the resources and capacity they need to manage any increase in presentations.

Decisions about the most appropriate levels of elective surgery are made by individual hospitals based on relevant state or territory advice. Refer to your college’s guidance and hospital for further advice on what can be performed in your location.

A: Yes. Avant’s Practitioner Indemnity Insurance policy will cover you for the work you do as a healthcare professional within your category of practice and that you are appropriately trained and qualified to do, subject to the terms, conditions and exclusions of the policy.

Coverage will not be refused where you exercise clinical judgment and your clinical decision to provide healthcare is determined to be inconsistent with the available advice in this fluid and uncertain environment. We recommend and trust that our members endeavor to follow the advice of government, their places of work, relevant professional bodies, colleges and societies, as well as peak decision-making bodies like the Australian Health Protection Principal Committee.

A: Yes. It is reasonable for the practice to have triage procedures in place to ensure appropriate precautions are taken to protect staff and other patients.

For up-to-date information about clinical and epidemiological evidence of COVID-19, visit the Australian Federal Government’s Department of Health website and the current national guidelines for public health units.

A: Yes. You may place signs telling people to call the reception desk and/or tell reception staff the moment they come in if they have symptoms suggestive of COVID-19 or if they have any clinical or epidemiological evidence for COVID-19. Visit the RACGP’s website for patient alert posters.

A: Doctors are not legally obliged to treat patients unless it is an emergency or a contractual requirement.

Discrimination laws prevent medical practice staff from discriminating against patients on the basis of disability/impairment (for example, COVID-19 or ethnic origin). However, you could refuse to see a patient if it is reasonably necessary to protect the health and safety of any person (including medical practice staff). In determining whether discrimination is “reasonably necessary,” you need to consider the up-to-date expert advice. View the Department of Health’s guidelines about managing patients with suspected COVID-19.

Practices and hospitals have an obligation under work, health and safety laws to ensure the safety of staff and patients at the practice.

In our view, it is reasonable to refuse to see patients with symptoms of COVID-19 if the practice cannot comply with the safety guidelines provided by the Department of Health and RACGP. View further information in our FAQs on PPE below.

A: A number of colleges and societies have issued advice about pregnancy and the risk of COVID-19, and about pregnant healthcare workers.

For more information see:

RANZCOG:
• COVID-19 and pregnant healthcare workers and other at-risk workers.
• A message for pregnant women and their families.

Australian and New Zealand Intensive Care Society:
• COVID-19 guidelines.

RACP:
• COVID-19 Guidance for pregnant healthcare workers.

For employed doctors who are pregnant, there is legislation entitling you to transfer to a safe job or not attend work in certain circumstances. You should seek specific advice about your personal circumstances.

This is general advice. You should consider whether there are any specific conditions or requirements in your contract of employment, services agreement and policies and procedures.

A: In Victoria, people are required to wear a face covering when outside their home unless a relevant exception applies (subject to a number of exceptions).

In NSW, it is recommended that people wear a face covering when outside their home if they are unable to maintain an appropriate physical distance.

In other locations, the current advice is that wearing a mask can help protect you and those around you if you are in an area with community transmission, and physical distancing is not possible, like on public transport.

As an occupier of a private medical practice you are entitled to take reasonable steps to protect your staff and other patients on the premises by making it a condition of entry that a person wear a face covering on arrival at the practice, unless they have a lawful reason not to wear a face covering. Patients who attempt to enter the premises in breach of these conditions may be removed for trespassing.

We recommend that you speak with a patient about their reason for not wearing a face covering before you exclude the patient from your premises. If the patient has a reasonable explanation (for example, a medical condition which prevents them from wearing a face covering safely), you should consider what other risk management strategies you can adopt to keep everyone safe. For example, you might consider asking patients who are not able to wear a mask to sit in a room other than the waiting room.

A: Testing guidelines are changing. To review the current national testing criteria, check the current version of the Communicable Disease Network Australia’s National Guidelines for Public Health Units and refer to your relevant state or territory guidance and public health unit advice. You can find links to advice from each state and territory health department in our resources section below.

A: No. Without patient consent, a doctor cannot generally perform testing. If you are concerned about a patient who has refused testing, you should contact the public health unit for advice. There are powers under state and territory-based legislation to compel testing in certain circumstances.

A: Yes, PPE must be worn when treating any suspect case.

The Commonwealth Department of Health and state and territory health departments have provided advice about the PPE required when testing or treating confirmed or suspected cases. Some hospitals have also provided advice about the PPE that is recommended.

The national guidelines explain what PPE is required.

Specific guidance is available from the Department of Health about using PPE in hospitals and non-inpatient settings.

A: Legally, yes. However, we acknowledge and appreciate the very difficult ethical dilemma this can create for doctors.

A practice/hospital cannot lawfully direct a worker to treat patients with suspected or confirmed COVID-19 unless the recommended PPE is provided.

This is because a practice/hospital and worker must ensure the workplace health and safety of the worker and other persons at the workplace as far as reasonably practicable by eliminating or minimising risks.

In considering how to manage risk, all parties should have regard to expert advice (such as the national guidelines for PPE advice and guidance about using PPE in hospitals and non-inpatient settings.

A: If face coverings are mandatory or recommended in your location, you can generally use your own face covering while transiting to and from work, and while in communal areas such as cafeterias.

The Commonwealth Department of Health state and territory health departments have provided advice about the PPE required when testing or treating confirmed or suspected cases. Some hospitals have also provided advice about the PPE that is recommended.

If you are not being provided with the recommended PPE for the type of work you are doing, you can ask your employer if you can wear your own PPE. PPE is a limited resource, so it is important for doctors to consider carefully whether they need it in particular circumstances. This includes PPE sourced by doctors personally. Wearing PPE when it is not recommended may set a confusing precedent in the practice or hospital (for fellow healthcare workers and the public/patients) and may undermine attempts to conserve PPE for high-risk encounters.

A: You will need to self-isolate if you had close contact with the patient and you were not wearing appropriate PPE at that time. For specific guidance about the management of any contact you may have had with a “confirmed”, “probable” or “suspect” COVID-19 case, you should review the Contact Management section in the current Communicable Disease Networks Australia’s National Guidelines for Public Health Units and contact your local public health unit for advice.

We are aware that the states/territories, and local public health units and districts, are distributing their own guidelines on self-isolation and testing, so you should be aware of the advice at your local level. You can find links to advice from each state and territory health department in our resources section below.

A: Doctors will need to carefully weigh up (and document) the harm to the patient of wearing a face covering against the potential harm of spreading or contracting COVID-19. It is a clinical decision as to whether someone will suffer harm by having to cover their face.

Face coverings are mandatory throughout Victoria when leaving the house (with a penalty of $200 for failing to do so without a reasonable excuse). The public health direction states that a face covering does not have to be worn if a person has a physical or mental health illness or condition, or disability, which makes wearing a face covering unsuitable. As a guide, the Department of Health and Human Services has advised that a face covering is not required in the following circumstances:

• A person who is affected by a relevant medical condition including problems with:
– their breathing made worse by covering the face
– a serious skin condition on the face aggravated by covering the face
– a disability or a mental health condition (examples may be claustrophobia or anxiety that are aggravated by covering the face). This also includes persons who are communicating with a person who is hearing impaired, where the ability to see the mouth is essential for communication.
• Persons for whom wearing a face covering would create a risk to that person’s health and safety related to their work, as determined through OH&S guidelines.

People with a disability must wear a face covering in Victoria unless it is impractical or unsafe to do so for medical, communication or other individual risk factors.

For further information on the Victorian position see the public health directions available on the DHHS website. These are updated regularly so it is important to review the current directions.

View our article on this topic.

A: The only type of ‘certification’ a doctor can provide is to the effect that, on the day of assessment, the patient was symptom free (this relies on a patient history and the patient being honest) and exhibited no clinical features indicating a viral infection or other symptoms that have been reported with COVID-19.

As the understanding of the disease evolves the spectrum of reported symptoms linked with this disease is changing. Detail of the currently known spectrum can be found in the Communicable Disease Networks Australia’s National Guidelines for Public Health Units.

For more information, read our article on medical clearance certificates.

A: Due to the public health importance of COVID-19, the new coronavirus strain (COVID-19) should be recorded on the medical cause of death certificate where the disease caused, or is assumed to have caused, or contributed to death.

View the Australian Bureau of Statistics’ ‘Guidance for Certifying Deaths due to COVID-19.’

• Record COVID-19 in Part I of the Medical Certificate of Cause of Death. All conditions and symptoms should be included. For example, in cases when COVID-19 causes pneumonia and fatal respiratory distress, both pneumonia and respiratory distress should be included along with COVID-19 in Part I alongside the duration of each disease and symptom. Certifiers should include as much detail as possible based on their knowledge of the case, medical records, laboratory testing, etc.

• Existing conditions, especially those which are chronic in nature, that may have also contributed to death should be certified in Part II of the Medical Certificate of Cause of Death. Chronic conditions may include, but are not limited to: coronary artery disease, COPD, diabetes, cancer or disabilities.

• The use of World Health Organization terminology COVID-19 or Coronavirus Disease 2019 should be certified on the death certificate. Terminology such as SARS-CoV-2 can be used, but it must be clear that it is the 2019 strain of disease. WHO terminology is preferred.

• The term ‘coronavirus’ should not be used in place of COVID-19 or Coronavirus Disease 2019. This will introduce uncertainty for coding cause of death which may lead to under reporting in national statistics.

A: As an employee, you are required to comply with the lawful and reasonable directions of your employer. If a direction is not lawful and reasonable, you are not required to comply with it.

Lawful: A direction is lawful if you can comply with it without breaching any laws. This would include the laws regarding your registration and professional indemnity insurance.

Reasonable: There is no single test to determine whether a direction is reasonable. The reasonableness of a direction will depend on a range of factors. In the case of a direction to work in a role outside your chosen specialty, you should consider issues such as:

• Do you have the relevant (and current) skills and experience needed to work in the role?
• Will appropriate supervision be provided?
• Will you be able to ensure patient safety in the role?
• Can you perform the role safely, particularly if you are a vulnerable healthcare worker?
• Will the hospital provide the appropriate resources (including PPE) for you to work safely in the role?
• Will the hospital provide the relevant training you need to be able to work in the role?
• Will you be indemnified for your work in the role?

If the answer to any of these questions is “no”, the requirement for you to work in the role may be unreasonable.

If you are concerned about being redeployed to a new role, you should speak to your Training Supervisor in the first instance, or your training college. It is important to remember that in your new role, you will need to have supervision in areas that you cannot work independently, and access to senior advice as you would in your normal scope of practice.

A: The General Practice colleges have advised that GP registrars should expect to be provided with the same level of supervision and support as required under the relevant college’s training standards. Patient and registrar safety remain key.

You should contact your relevant regional training organisation for more information on managing remote supervision.