GA 2020/0821
Answer
No. Not unless the circumstances are such that you are effectively activating a new referral.
Context
When one physician covers another’s inpatients who have already been admitted, but are new to the doctor covering for the weekend, Dr A wanted to know if it is acceptable to bill a 110? Dr A’s instincts were that all encounters should be billed as 116 since they are generally part of the same episode of care, (even if provided by a different physician) but she had received conflicting advice.
Relevant considerations here are the ‘single course of treatment principle’ and the ‘locum tenens’ arrangements.
This answer should be read in conjunction with GA 2020/0720
Relevant Legislative Provisions
Health Insurance Regulations 2018
Health Insurance (General Medical Services Table) Regulations (No. 2) 2020
Other Relevant Materials
Published academic journal article that provides some analysis of the challenges around compliance with referral requirements and the low levels of legal literacy around the operation of relevant referral law: Wading through Molasses: A qualitative examination of the experiences, perceptions, attitudes, and knowledge of Australian medical practitioners regarding medical billing.
Case law
N/A
Departmental Interpretation
mbsonline.gov.au (accessed 27 July 2020)
Definition of a Single Course of Treatment
“A single course of treatment involves an initial attendance by a specialist or consultant physician and the continuing management/treatment up to the stage where the patient is referred back to the care of the referring practitioner. It also includes any subsequent review of the patient’s condition by the specialist or the consultant physician that may be necessary. Such a review may be initiated by either the referring practitioner or the specialist/consultant physician. The presentation of an unrelated illness, requiring the referral of the patient to the specialist’s or the consultant physician’s care would initiate a new course of treatment in which case a new referral would be required. The receipt by a specialist or consultant physician of a new referral following the expiration of a previous referral for the same condition(s) does not necessarily indicate the commencement of a new course of treatment involving the itemisation of an initial consultation. In the continuing management/treatment situation the new referral is to facilitate the payment of benefits at the specialist or the consultant physician referred rates rather than the unreferred rates. However, where the referring practitioner:- (a) deems it necessary for the patient’s condition to be reviewed; and (b) the patient is seen by the specialist or the consultant physician outside the currency of the last referral; and (c) the patient was last seen by the specialist or the consultant physician more than 9 months earlier the attendance following the new referral initiates a new course of treatment for which Medicare benefit would be payable at the initial consultation rates.“
servicesaustralia.gov.au (accessed 31 July 2020)
“Single course of treatment
A referral will cover a single course of treatment for the referred condition. A single course of treatment is an initial attendance by the specialist or consultant physician. The single course of treatment includes subsequent attendances for the continuing management of the condition until the patient is referred back to the referring practitioner.
A new referral doesn’t always mean a new course of treatment.
If a referral is for continuing management of a condition, the specialist or consultant physician must bill subsequent attendance items. However, an initial attendance item can be billed if:
- the referring practitioner decides the patient’s condition needs to be reviewed, and
- the patient is seen by the specialist or consultant physician after the expiry of the last referral, and
- the patient was last seen by the specialist or consultant physician more than 9 months earlier
If the patient has a new or unrelated condition, the specialist can start a new course of treatment if there is a new referral in place.“
mbsonline.gov.au (accessed 27 July 2020)
“Locum-tenens Arrangements
Fresh referrals are not required for locum-tenens acting according to accepted medical practice for the principal of a practice ie referrals to the latter are accepted as applying to the former and benefit is not payable at the initial attendance rate for an attendance by a locum-tenens if the principal has already performed an initial attendance in respect of the particular instrument of referral.”
servicesaustralia.gov.au (accessed 1 August 2020)
“Health professional details required on account or receipt
Under section 51 of the Health Insurance Regulations 2018, you must include certain information on an account or receipt.
You can provide either or both:
- the name of the health professional that’s providing the service and address of the place of practice for the service
- the provider number of the health professional.
We can record more than one practice location for you. Always use the provider number for the practice location where you provide the services.
When a locum provides a service on behalf of another health professional, the account documents must use either:
- the word Locum
- the letters LT.(Locum Tenens).“
Detailed Reasoning
The Single Course of Treatment Principle
To start, it is important to understand the “Single Course of Treatment” principle described in the regulations. The overarching policy objective of this principle is to support Australia’s gate-keeper model health system, in which the GP is the focal point of patient care. The regulations provide:
“(2) A single course of treatment for a patient:
(a) includes:
(i) the initial attendance on the patient by a specialist or consultant physician; and
(ii) the continuing management or treatment up to and including the stage when the patient is referred back to the care of the referring practitioner; and
(iii) any subsequent review of the patient’s condition by the specialist or consultant physician that may be necessary, whether the review is initiated by the referring practitioner or by the specialist or consultant physician; but
(b) does not include:
(i) referral of the patient to the specialist or consultant physician; or
(ii) an attendance (the later attendance) on the patient by the specialist or consultant physician, after the end of the period of validity of the last referral to have application under regulation 31 of the Health Insurance Regulations 1975 if:
(A) the referring practitioner considers the later attendance necessary for the patient’s condition to be reviewed; and
(B) the patient was most recently attended by the specialist or consultant physician more than 9 months before the later attendance.“
In practice what this means is the following:
- Once you have finished treating the condition described in the referral, your patient should be directed back to their GP.
- You should not “pass the patient” around among your colleagues. In-hospital referrals are a separate issue, which we will deal with below, but even outside of hospital, the system has been designed to send patients back to GPs, not passed to and fro between specialists.
- A new referral and even a new hospital admission does not necessarily mean you can claim an initial attendance item. If a patient you have recently treated presents through the emergency department over the weekend and is admitted under your care, but you have already treated the patient for the same condition which caused them to come to hospital, you should claim subsequent attendance items because you are treating the same condition which is a single course of treatment. Of course, if the patient comes in with something completely unrelated to the condition you have been treating you can claim an initial attendance – this would usually be facilitated via a new referral from the emergency physician.
- The law states that if it’s been more than 9 months since you last treated the patient, and the referral has expired, you can claim an initial attendance if clinically relevant.
Now to the Locum Tenens Arrangements.
There is actually no definition of ‘locum tenens’ anywhere in the legislative scheme. It is dealt with at the item number level in Health Insurance (General Medical Services Table) Regulations, one example of which is copied for your benefit below.
Medicare’s interpretation of the locum arrangements has always been the same as per the bolded text above under ‘Departmental Interpretation’, namely, that if an initial consultation has already taken place under the referral, the locum cannot claim another one. When the locum sees the patient for the first time, she can only claim a subsequent consultation, such as a 116, even though it may be the first time she has ever laid eyes on the patient.
Returning now to this specific question, if you are the first person to see the patient under the referral, then you can and should claim the initial consultation, even if it means the doctor to whom the referral is named is prohibited from claiming an initial consultation when she sees the patient. It’s basically a first in first served system.
It is really of no relevance to Medicare who activated the referral, but once activated by the claiming of an initial consultation, all locums should thereafter claim subsequent consultations.
Examples and other relevant information
A key take away is that fresh referrals are not required. The following two case studies illustrate common scenarios.
Case study 1
Dr Mark Jones is an oncologist. Mark and three other oncologists are all based out of the same practice and they cover for each other as required.
Dr Jones currently has a patient called Barry who is undergoing chemotherapy treatment in the private hospital. Dr Susan Smith is covering everyone’s patients for the weekend.
Prior to finishing up on Friday, Dr Jones writes in Barry’s inpatient notes that Dr Smith will review over the weekend.
Dr Smith sees Barry for a review on Saturday and Sunday and invoices the private insurer for the two weekend visits to Barry, and on her claim she records Dr Jones as the referring doctor, based on the note in the patient’s file. This creates a new referral in favour of Dr Smith.
This process is non-compliant with the ‘in-hospital’ referral provisions of the law, which we recommend you learn by reading GA 2020/0720. It will also create overlapping referrals.
The locum tenens provisions apply here, and must be read in conjunction with other provisions in the Regulations.
Dr Smith should use the ‘in-hospital’ override to bill her claims on the weekend and may need to also add the word “locum” or “LT” depending on the services she is claiming (see case study 2)
In an outpatient context it is slightly different. Let’s say Susan was covering for Mark in his rooms and it’s therefore no longer an ‘in-hospital’ referral, Susan should use the locum tenens provisions and include the name of the original referrer who referred the patient to Mark on her claims (usually the GP), and add a note in the ECLIPSE note field saying “locum” or “LT”.
NB: These claims will sometimes reject, even if you populate all data fields correctly. When that happens, the only way to fix it is to call Medicare.
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Case study 2
Mrs Molly Maple is an inpatient in a private hospital under the care of Dr Peter Cox. On Monday Dr Cox claimed an item 132 for his long consultation with Molly.
On Tuesday, Dr Stephen Harris is covering for Dr Cox and reviews Molly. The correct item number for the service he provides is item 133, which he claims. But the claim is immediately rejected because the pre-requisite item 132 has not been claimed by Dr Harris (it was claimed by Dr Cox).
This happens often unfortunately, so you will need to resubmit the claim adding the word “locum” or “LT” in the notes field of the claim and then keep your fingers crossed! You will probably have to call Medicare as well.
Who this applies to
All specialists covering for each other.
When this applies
Always