Answer:
An entry in the patient’s hospital record.
Context:
This is a common question that causes confusion, as well as rejected claims. The second part of the submitted question was – who should the referring doctor be?
Relevant Legislative Provisions
Health Insurance Regulations 2018
Other Relevant Materials
Please read this answer in conjunction with GA 2021/0126 and GA 2021/0230
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
As we have stated in other answers, referral law is not straightforward. However, in the common scenario of a patient being referred to admitted care from an
Emergency Department (ED), there are only a few areas that cause problems.
Regulation 98 sets out the basic requirements of referrals, which must be:
(a) in writing; and
(b) signed by the referring practitioner; and
(c) dated.
Then regulation 100 provides separate information regarding in-hospital referrals as follows:
“Requirement to record certain referrals in hospital records
If a referral is for a patient in a hospital who is not a public patient, approval of the referral by the referring practitioner must be included in the hospital records. The approval must be signed by the referring practitioner.”
Applying the law to the facts in this question:
- Referrals from ED to the wards are only an issue if a patient is ‘not a public patient’. That means, the patient either a) has presented to a public hospital ED and is going to be admitted and has elected to be private or b) has attended a private ED and a decision to admit has been made.
- Sometimes the hospital is aware that a patient in a public ED has private health insurance, but the patient may not yet have decided whether or not they want to use it. In these circumstances, it is a good idea for the ED clinician to write a valid referral in the hospital records before the patient goes up to the ward, so it can be activated IF the patient subsequently makes a private election. If the patient decides to remain a public patient nothing is lost.
- Once a decision to admit has been made, the relevant referral should be entered in the patient’s hospital record in accordance with regulation 100, and must also be signed and dated.
- In terms of who can refer, in small EDs staffed with nurse practitioners and junior doctors, usually the Director of the ED is the relevant referrer. However, in larger EDs any of the emergency physicians can be the referrer.
- Do not use JMOs (interns and RMOs) as referrers for private patients because they cause Medicare claims to reject. They have not yet reached a stage in their training where their provider numbers allow them to refer privately. If a referral is entered by a JMO, regulation 100 provides that it must be ‘approved’ by the referring practitioner (noting JMO’s can’t refer). So either the ED consultant should countersign the referral, or just write it him/herself.
- Nurse practitioners will NOT cause claim rejections so if you have them, they can refer. Regulation 96(6) provides that nurse practitioners can refer a patient to a specialist or consultant physician.
- In the common scenario of a patient being transferred between hospitals – for example, a patient presented to a private ED, but required transfer to a public ED, or was discharged from hospital A and will be admitted through the ED of hospital B – you still need a valid referral. It does not need to be a separate document called a referral, but must be in writing, signed and dated and accompany the patient to the new hospital. Often this is found on the discharge/transfer summary.
- In some circumstances the clinicians on the wards may be able to use the in-hospital override function when billing, and not name a referrer at all, because the referral is evident in the hospital records. Please read GA 2021/0126 before you do this.
Examples and other relevant information
The problem with ED Directors being named as the referring doctor for hundreds and sometimes thousands of patients (to overcome the JMO issue) is that they receive thousands of letters back from the treating clinicians for patients they don’t remember, didn’t personally treat or may never have heard of!
Nothing can be done to resolve this at the moment. Referral law needs to be comprehensively overhauled.
Again, we strongly suggest you read GA 2021/0126 and GA 2021/0230 to learn more about in-hospital referrals.
Who this applies to
All hospital based clinicians including nurse practitioners.
When this applies
Always.