GA 2021/0128
Answer
Part A – Yes
Part B – Any medical practitioner except a junior medical practitioner.
Context
Dr A was unsure about correct referral pathways for patients transferred to a private hospital after an episode of care in a public hospital, and how such patients should be billed.
Relevant Legislative Provisions
Health Insurance Regulations 2018, Regulations 58(4), 100 and 102(5)
Other Relevant Materials
The National Health Reform Agreement (NHRA)
Published academic journal article of qualitative interviews with doctors (including salaried medical practitioners). One participant was audited by Medicare in circumstances similar to those described in this question, and Medicare appeared to have been unclear about the application of its own rule: Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.
Please read this answer in conjunction with GA 2021/0126 and RM 2020/067
Case law
N/A
Departmental Interpretation
Relevant content from the MBS (accessed 20 January 2021)
“(iii) Hospital referrals…
Specialist Referrals Where a referral originates from a specialist or a consultant physician, the referral is valid for 3 months, except where the referred patient is an admitted patient. For admitted patients, the referral is valid for 3 months or the duration of the admission whichever is the longer.”
Detailed Reasoning
The law of referrals is confusing so let’s review some key provisions:
“Referrals given by particular persons
(2) A referral given by a specialist or consultant physician is valid:
(a) for a maximum of 3 months after the first service given in accordance with the referral; or
(b) if the referred person is a patient in a hospital at the time of referral and continues to be so for more than 3 months—until the person ceases to be a patient in a hospital.
Special cases
(5) A referral for a professional service to a patient in a hospital who is not a public patient is valid until the patient ceases to be a patient in the hospital who is not a public patient.“
It is certainly unclear – on one reading sub-reg 2(b) seems to contradict sub-reg (5) by suggesting a referral can be carried over for 3 months even after a patient is discharged.
However, sub-reg (5) states that a referral for a patient in a hospital who is not a public patient, expires on discharge. Ultimately, it makes little difference because you should obtain a separate referral (not the referral in the patient’s hospital file) if you plan to continue treating the patient after discharge. It is a grey area unfortunately.
When a patient is transferred from a public hospital to a private hospital (irrespective of whether that patient had elected to be public or private during their public admission), as long as there is a separate referral document that physically accompanies the patient to the private hospital, that will be sufficient to meet valid referral requirements. Please note, as I said, while it is a grey area, the best advice is that you should not rely on a referral written in the patient’s public hospital record. Arrange a new one before the patient is discharged and take it with you to the private hospital.
Also, a referral written by a junior medical officer will cause your private claims to reject, so the referral should come from the relevant consultant who the patient was under in the public hospital.
If that was you and you are moving your patient from a public to a private hospital, then you will need a new written referral from whoever originally referred the patient to you in the public. You cannot self refer. So let’s say the referral originated from the ED. You should obtain a new written referral from that same ED doctor on a separate document to carry with you to the private hospital. I know this is impractical, I know!
In regards what to bill, it is assumed you are querying whether you should bill an initial or subsequent consultation the first time you see the patient in the new private hospital setting. It is another grey area unfortunately.
Best advice is always to return to basic principles and choose the item number that most accurately describes the service you have provided – which is not always as easy as it sounds in practice. Your options are:
- If this is not the first time you have seen the patient, because you also treated the patient in the public hospital, and you are treating him/her for the same condition in the private hospital, then bill the appropriate subsequent attendance item, not an initial attendance. However, please be aware this can trigger a Medicare audit as it did for the doctor who was interviewed in the above academic paper. So all you can do is keep comprehensive records of the billing decision you have made via your adequate and contemporaneous records detailing the service you provided.
- If you are seeing the patient for the very first time – meaning the patient was not under your care in the public and this is the first time you have laid eyes on the patient – then you can bill the relevant initial attendance item and continue from there.
Examples and other relevant information
Referral law needs a major overhaul. It is largely incoherent, which has led to multiple, overlapping referrals for the same patient and doctor being common. You would all have had the experience where you have an open referral from a GP, another from the ED physician and still another from another colleague working within the same hospital, all for the same patient. So it sometimes feels like you can take your pick which referral you put on your claims. The law was never intended to work in this way but unfortunately, it does.
Until necessary law reform is undertaken, all you can do is do your best to ensure you always have a valid written referral kept in your records, not in a hospital’s records.
You can legally take over a referral that names one of your colleagues of the same specialty. See RM 2020/067.
Who this applies to
All specialists.
When this applies
Always.