GA 2021/0126
Answer
In a complex and opaque way unfortunately, with legal grey areas.
Context
A specialist doctor asked how the various specialists below should claim for their services in this very common scenario.
Patient attends the Emergency Department (ED). The ED Dr refers the patient to Dr A and Dr B (of different specialties) for inpatient management of a complex presentation. Dr A performs an initial consultation and is then covered for a few days by Dr C. Dr B performs an initial consultation, which identifies another problem requiring the expertise of Dr D. At the end of the admission, there are outstanding specialist issues that require outpatient follow-up with Drs A and D.
1. Should all four specialists bill using the in-hospital override for all consultations? Can A, B and D all claim a 110 or 132 as reflective of the service they provided?
2. If C identifies a new issue that requires assessment and a change in treatment, can C claim an in-hospital 110 (non locum tenans)?
3. If A and D use an in-hospital override for inpatient claims, and then receive a subsequent Medicare-compliant referral for outpatient review of the issue(s) managed during the admission, does the outpatient review occur “after the end of the period of validity of the last referral to have application” (because the last referral expired at hospital discharge). If so, can they claim a 110?
Relevant Legislative Provisions
Health Insurance Regulations 2018, Regulations 58(4), 100 and 102(5)
Other Relevant Materials
Please read this answer together with GA 2020/0821 and GA 2020/0823
Case law
N/A
Departmental Interpretation
Relevant content in the MBS (accessed 20 January 2021)
(iii) Hospital referrals.
Private Patients – Where a referral is generated during an episode of hospital treatment for a service provided or arranged by that hospital, benefits will be payable at the referred rate if the account, receipt or assignment form is endorsed ‘Referral within (name of hospital)’ and the patient’s hospital records show evidence of the referral (including the referring practitioner’s signature). However, in other instances where a medical practitioner within a hospital is involved in referring a patient (e.g. to a specialist or a consultant physician in private rooms) the normal referral arrangements apply, including the requirement for a referral letter or note and its retention by the specialist or the consultant physician billing for the service.
Detailed Reasoning
Medicare’s referral system was designed in the 1970’s, and while it is an important cost control mechanism in the scheme, it definitely struggles to accommodate modern hospital practice where admitted patients are often treated by many different specialists. The law was originally designed such that there should really only ever be one active referral for a patient in a hospital bed (ideally from a GP or the Emergency Department), but this doesn’t always translate in practice. That said, if used correctly, the in-hospital referral override is intended to prevent patients having multiple open and overlapping referrals, which have become so common.
Regulation 58 (4) prescribes the words ‘referred within‘ followed by the name of the hospital, be included on relevant claims submitted using the in-hospital referral function.
Regulation 100 provides that the referral must be written in the patient’s hospital records and signed by the referring practitioner.
Regulation 102(5) provides that a referral written in a patient’s hospital records expires upon discharge.
Applying the law to the given scenario:
- The initiating referral has come from an ED Dr, who must be a consultant NOT an Intern or RMO. Claims made to Private Health Insurers will reject automatically if the referring doctor does not have consultant or senior registrar status. For this reason, many referrals from ED are recorded using the name of the Department Director.
- The ED Dr has referred the patient to two colleagues of different specialties for treatment of different conditions, which is common and clinically appropriate. Therefore, both Drs A and B should use the ED Dr as the referring Dr on their claims, because they have effectively each received a separate referral from Dr ED. Both can therefore claim the appropriate initial attendance item when they first see the patient.
- When Dr C is locuming for Dr A she should use the in-hospital override for her referral and NOT claim an initial attendance item the first time she sees the patient. She should instead claim the appropriate subsequent attendance item for her specialty. See GA 2020/0821 for an explanation about this.
- When Dr D sees the patient, he should use the in-hospital override and he can claim the appropriate initial consultation item because it is a separate clinical condition under a new referral (noting the in-hospital referral constitutes a new referral) and Dr D is not acting as a locum.
- If Dr C diagnoses another new condition, she can claim the relevant initial consultation item such as 110, using the in-hospital override again, BUT she should notate the claim with the words ‘new condition’ prior to submitting her claim for payment.
- Drs A and D will each need new, separate referrals that they can take into their private rooms practice to enable them to continue to treat the patient after discharge. The doctor who is discharging the patient (not an intern or RMO – same problem) should arrange this.
- Drs A and D cannot claim item 110 just because the in-hospital referral expired on discharge and they are activating a new referral. Please read GA 2020/0823 for an explanation about this.
Examples and other relevant information
ALL in-hospital referrals must be recorded in the hospital file, not on your iPhone. Writing something as brief as “referred to rehab” is standard practice and compliant as long as you write your name and sign the relevant entry in the patients’ notes. There must be a written record and it must exist inside the patients hospital record according to the law. So whilst the reality is that doctors run around the wards all day messaging each other to see patients, or even making ‘corridor’ referrals, it is important you protect each other by ensuring you remember to drop up to the ward and write the referral in the patients’ notes (including signing and dating it) before you head home for the day.
IN A NUTSHELL:
FIRST – A referral in a patient’s hospital record:
- is a valid referral, but it expires when the patient is discharged from hospital, and
- it cannot be used for ongoing care in private rooms
HOWEVER: If the same referral is written as a separate letter, as well as being noted in the hospital record, it can continue to be used after discharge in private rooms and the usual referral periods apply. This will usually be 3 months.
SECOND – A referral written in a patient’s hospital record must include:
- The date it was written
- The name and signature of the referring doctor
- A statement such as “referred for oncology/rehab/cardiology review” The reason for the referral should be self evident from the clinical notes in the patient’s file.
THIRD – As a rule of thumb, only claim an initial consultation if you are the first clinician to see the patient for a particular problem, having received the referral from one of your colleagues. If you are covering for someone else who has already worked up that problem, you should claim a subsequent consultation. Providing second opinions is a grey area, but the best and safest approach is to claim a subsequent consultation.
Who this applies to
All medical practitioners practicing hospital based medicine in both public and private hospitals. The law applies to “a patient in a hospital who is not a public patient” which includes ‘private in public’ and ‘private in private’.
When this applies
Always