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out of date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.
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.
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
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
- in date when the patient sees the
- received before or at the time of the
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
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
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.
- 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
The RACGP’s Standards for General Practices
(4th edition) provides guidelines on
writing referrals to specialists.
This article was first published in Medical Observer.
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