Private Health Insurance

How do I correctly administer a known-gap claim without breaking the law that applies to illegal split bills?

8 December 24

I’m working as a surgical assistant. I sometimes charge the patient a gap. My registration with each fund is ‘known gap’. As an example – Bupa pays $386 for assisting a 49518. I want to charge the patient $100 gap. Do I need to charge the fund $486? and then charge the patient $100 or do I charge the fund $386 (under their known gap scheme flag) and separately bill the patient $100. I’m confused about split billing – what is allowed and what isn’t allowed and where we can charge the fund only their known gap scheme amount and where we have to charge the fund the entire amount or whether this is actually what’s always needed?

Can an inpatient of a private psychiatric hospital attend bulk billed outpatient appointments whether by telehealth or face-to-face?

28 October 24

This question came from a consumer. I am an inpatient in a private mental health unit in a private hospital. I am under an inpatient psychiatrist. While I am an inpatient, I have a telehealth review consultation booked with an outpatient psychiatrist who is known to me. I also have a review consultation with an outpatient specialist in person, and a review consultation in an outpatient clinic at a public hospital. I am allowed to leave the private hospital to attend the in-person consults and will then return. But I have heard that these services can’t be bulk billed. I am a pensioner so cannot afford private fees.

Why are outpatient item numbers that attract 85% of the Medicare Schedule Fee not listed by the private health insurers?

3 October 24

The question was posed in the context of public hospital outpatient services where clinicians can bulk bill when exercising a Right of Private Practice providing all other criteria are met. The questioner wanted to know how they easily determine which item numbers should be claimed at 75% and which 85% because the Private Health Insurance (Benefit Requirement) Rules do not seem to include some MBS item numbers that are relevant to outpatient services and normally claimed at 85% of the schedule fee, such as telehealth and face-to-face consults, and the associated bulk bill incentives.

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Topics

Specialities

Private Health Insurance

How do I correctly administer a known-gap claim without breaking the law that applies to illegal split bills?

Can an inpatient of a private psychiatric hospital attend bulk billed outpatient appointments whether by telehealth or face-to-face?

Why are outpatient item numbers that attract 85% of the Medicare Schedule Fee not listed by the private health insurers?

Topics

Specialities

Private Health Insurance

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