What to do when a patient requests a backdated referral

Jul 4, 2017

It is a busy afternoon, and a patient phones you asking for a referral for a follow-up specialist appointment she attended a month earlier. You had initially referred her to the specialist and that referral had expired. The patient is at the Medicare office trying to claim a rebate for the specialist visit, and explains that Medicare would not pay a claim for the specialist consultation because the referral was out of date

Can you help the patient by backdating a referral?

GPs often feel caught in the middle when this scenario arises. They can feel an obligation to help their patient who will otherwise be left out of pocket without a current referral.

However, there is no leeway in this situation. It is unlawful to backdate a referral and GPs should not agree to such requests. Under the provisions in the Commonwealth Health Insurance Act, stiff penalties can apply for making false or misleading statements in relation to Medicare. This can also lead to disciplinary action by AHPRA.

Further, backdating referrals can result in Medicare declining to pay Medicare benefits or requiring repayment of benefits if they have been paid incorrectly.

Requirements for valid referrals

A valid referral is required before a specialist can itemise the consultation so the patient is eligible for Medicare benefits.

To be valid a referral must be:

  • in writing;
  • signed and dated by the referring doctor;
  • in date when the patient sees the specialist; and
  • received before or at the time of the specialist consultation.

Referrals from a GP to a specialist last for 12 months unless otherwise specified. If the specialist on-refers to another specialist, the specialist referral is only valid for three months.

If a patient’s condition needs continuing care and management by a specialist or consultant physician, GPs can write a referral for longer than 12 months. An indefinite referral to the specialist or consultant physician can be provided where appropriate.

However, if a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition, even if for the same specialist.

In some situations, provisions are made for Medicare benefits to be paid if a referral has been lost, stolen or destroyed. In those cases the patient must declare to the specialist that a referral was completed by a referring practitioner, but was not delivered to the specialist because it was lost, stolen or destroyed. The patient must be able to provide to the specialist the name of the referring practitioner and the practice address or the provider number of the referring practitioner.

There are also situations where referrals are not necessary, such as pre-anaesthetic consultations, emergencies and referrals of private patients in hospital.

So what can you do?

GPs can introduce risk management strategies in a bid to avoid requests for backdated referrals from patients:

  • Ensure all practice staff and patients understand why a valid referral is important, and what constitutes a valid referral. It is important to note that the usual 12-month time period for referral validity starts at the time when the specialist first sees the patient, and not when the initial referral is dated.
  • Reception staff should be trained and equipped to caringly and politely push back requests from patients for backdated referrals. Remember it is often not the patient’s fault that the referral is out of date.
  • When referring patients to a specialist, emphasise why a valid referral is important and the time the referral is valid if they are having ongoing care from the specialist. If this aligns with your own practice policy, let patients know that if their referral is out of date they can call on the day of a specialist appointment to request a referral that can be sent directly to the specialist.
  • You may wish to have a notice displayed in your waiting room about referrals which may remind patients about requesting an updated referral if theirs may be out of date.
  • In the interests of working together for the benefit of patients, good communication between GP and specialist is crucial. Consider a courtesy call to the specialist rooms, reminding them that requests for backdated referrals will be refused and are unlawful. Encourage them to call your rooms on the day of the follow up appointment and inform them of your practice referral policy.

Key points:

  • GPs should never agree to requests to backdate a specialist referral
  • Ensure all practice staff know backdated referrals will not be provided to patients under any circumstances
  • Introduce strategies to educate patients about the importance of having a valid referral before visiting a specialist

Further information

The RACGP’s Standards for General Practices (4th edition) provides guidelines on writing referrals to specialists.

This article was first published in Medical Observer. Read the original article here.

Share your view

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