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Referrals, initial consultations and Medicare compliance

May 8, 2015

Medicare is conducting compliance audits of specialists’ billing; particularly where more than one initial consultation is rendered in respect of a single referral.

The consequences of incorrect itemisation or rendering services without a valid referral can be expensive - repayment to Medicare of 100% of the benefits paid for the service and significant additional administrative penalties. The audits emphasise the importance to specialists of ensuring correct administrative practices with respect to referrals.

Do you have a valid referral?

Generally a valid referral is required before a referred specialist consultation can be itemised. Pre-anaesthetic consultations, emergencies and referrals of private patients in hospital are exceptions.

A valid referral must be:

  • in writing; 
  • signed and dated by the referrer; 
  • in date at the time the consultation service is rendered; and 
  • received prior to or at the time of the specialist consultation.

It is unlawful to back-date a referral, so referring practitioners should not be asked to do so.

Referrals may be specified to be for any relevant period (including indefinitely if necessary). If the duration is unspecified it is assumed to be for 12 months (if referred by a GP) or three months (if referred by another specialist).

The duration of the referral commences on the day of the initial consultation, not the date on which the referral is written.

When is a new referral required?

Broadly, a new referral will be required:

  • where the patient requires further specialist input to the management of the condition for which they were previously referred but the referral has expired; and
  • where specialist input to an unrelated condition is required.

It is important that a new referral is sought where an unrelated condition requires specialist treatment and that the new valid referral is received prior to the commencement of treatment for that condition.

It is equally important to ensure your practice staff are aware that the need for a new referral does not necessarily enable an initial consultation service to be itemised.

When can you itemise an initial consultation?

The Medicare Benefits Schedule (MBS) item descriptor for initial consultation items (e.g. 104, 110 etc) states the items are an “initial consultation in a single course of treatment”. A single course of treatment is defined as follows:

“… an initial attendance by a specialist or consultant physician and the continuing management/treatment up to the stage where the patient is referred back to the care of the referring practitioner. It also includes any subsequent review of the patient's condition by the specialist or the consultant physician that may be necessary. Such a review may be initiated by either the referring practitioner or the specialist/consultant physician.

The presentation of an unrelated illness, requiring the referral of the patient to the specialist's or the consultant physician's care would initiate a new course of treatment in which case a new referral would be required.”

Where an unrelated condition requires treatment an initial consultation can be itemised but a new valid referral must be received prior to consulting the patient.

However, simply because the patient requires a new referral because the previous referral has expired does not entitle the specialist to bill another initial consultation service unless it is at least nine months since the patient was last seen for that condition and the referring practitioner deems further review necessary.

Examples

Ongoing six-monthly consultations for management of a single condition may require a new referral if an indefinite referral has not been given but will ordinarily not allow more than one initial consultation service to be billed.

Conversely, a single yearly consultation for an ongoing condition seen on the basis of a 12 month referral may allow an initial consultation item to be billed for each consultation if review is deemed necessary.

Key points

  • Specialists need to be aware of the importance of correctly itemising initial and subsequent referred consultations. 
  • Check that you have a valid referral – in writing, signed and dated by the referrer and received prior to or at the time of the specialist consultation. 
  • Back-dating a referral is unlawful. 
  • Check that you understand when you need a new referral – particularly where a patient presents with an unrelated condition.
  • Ensure your practice staff understand the circumstances in which you can bill for an initial consultation.

Specialist referrals and initial consultations: decision-making flowchart

For more information on specialist referrals and initial consultations refer to Avant’s decision-making flowchart

If you have any specific questions or are requested to complete an audit, it is imperative that you seek advice from our Medico-legal Advisory Service on 1800 126 268 promptly to maximise your opportunity to correct any errors and avoid or reduce administrative penalties.

Learn more

Read our Risk IQ fact sheet, Take a R.E.S.T and stay out of trouble with Medicare.

Share your view

We welcome your feedback on this article – email the Editor at: editor@avant.org.au