Correctly billing services is not only important to meet your obligations as a healthcare provider, it ensures efficient payment of your fees. Having a claim short paid or rejected can add to your administrative time and cost you.
Therefore, it’s worth minimising exchanges with Medicare and health funds when looking after privately insured patients. The complexity of the Medicare and private health insurance landscape means billing mistakes happen, so here are some things to look out for.
Compliance with the MBS
Medicare rejections are one of the more common reasons for an unpaid claim. Medicare will reject claims for payment where an item number is not billed according to the MBS requirements. More often than not these are made inadvertently, and can include:
- using out-dated MBS item numbers,
- not adhering to co-claiming limitations,
- not providing additional clinical information where required, and
- billing surgical items in the incorrect sequence.
When a claim is rejected by Medicare, your patient’s health fund will follow up with you for more information, until Medicare is satisfied and can process your claim.
The health fund should provide as much information as possible to facilitate this process – although despite best efforts, missing or incorrect information can lead to delays in payment.
Medicare rejections also impact the payment of health fund benefits. Until Medicare pays their 75% portion on a claim for a private patient, the remaining 25% from the health fund, and any additional gap cover payments, can’t be paid.
Covering the gap
Choosing to participate in your patient’s medical gap cover means abiding by the rules of that cover to ensure the desired billing outcomes. A health fund is unable to cover the gap and will short pay your claim by only paying 25% of the Medicare fee if:
- your registration with their scheme isn’t active,
- you haven’t identified you’re billing your claim according to their scheme when you submit it, or
- you exceed the allowable ‘known-gap’ fees of that scheme.
The current private health insurance landscape means there are several gap schemes, each with their own billing guidelines. Staying up to date with the terms and conditions of any health fund medical gap cover schemes you intend to participate in, will reduce instances where your claim may be short paid.
Taking time early on to bill correctly means you can spend more time on your most important role of treating your patients.
Services to support your billing
Electronic claiming through ECLIPSE has made billing with health funds faster and more secure. If a claim does get rejected, you can rectify this mistake and resubmit your claim with a much shorter turnaround time. A growing number of claims are received electronically. We encourage you to implement ECLIPSE claiming into your practice if you haven’t already and see how it can help with a smooth payment process.
Doctors’ Health Fund provides health cover* designed for doctors. Their Top Cover Gold hospital policy pays medical benefits up to the AMA list of services and fees, and with no preferred provider networks for extras, you choose your health care providers. To find out more or to contact their expert team, visit doctorshealthfund.com.au
*IMPORTANT: Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy, available at www.doctorshealthfund.com.au/our-cover.
A version of this article was published in issue 19 of Connect magazine.