GPs encouraged to report ‘double dipping’ hospitals

Anastasia Tsirtsakis

31/01/2022 4:34:25 PM

The advice comes amid reports of public hospitals mandating named referrals as a way of claiming MBS items.

A GP looking at his laptop inquisitively.
A named referral is only required for private services in an out-patient setting.

GPs are being asked to notify the Department of Health about public hospitals that appear to be mandating named specialist referrals for people seeking to access outpatient clinics.
Doctors have been encouraged to raise concerns via the Health Provider Tip-off form, following an apparently growing trend of hospitals seeking to claim Medicare Benefits Schedule (MBS) items.
Dr Emil Djakic, a member of RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), told newsGP the request from hospitals is creating confusion for GPs and inconveniencing patients.
‘If we go back to the actual Medicare interpretation of a referral, it says there is no need to even name a specialist,’ he said.
‘So how do those two pieces of information sit together? It’s again another example of general practice being used to fill the gaps between a broken system.
‘I’ve seen the phrases of double dipping used around it, and I think it is.’
Clause G19b of the 2020–2025 National Health Reform Agreement (NHRA) states that a named referral is only required for patients accessing services through a public outpatient clinic as a private patient.
‘Under the NHRA, public hospital outpatient clinics must not control referral pathways by requiring named referrals for access to the clinic,’ the DoH has said.
The agreement stipulates that patients who choose to go public should be provided care at no cost and with no charges raised against Medicare, whereas those who opt to be treated as a private patient may face out-of-pocket costs and may be able to claim Medicare benefits and private health insurance rebates.
The DoH is firm in its stance that ‘the choice to be public or private is for the patient, patient’s carer or other authorised party to make, with informed financial consent’, given the out-of-pocket costs that can accompany private care.
‘Even if a patient has a named referral, the patient can still opt to be treated as a public patient,’ the DoH notes.
However, there is concern that private patients are regularly not being informed of their ability to claim a Medicare rebate, particularly if the hospital requests that they obtain a ‘named’ referral rather than a ‘private’ referral.
‘[The Government] let this develop where they’ve allowed specialists to sit in private clinics and bill externally, which is the states cost shifting outpatient services into the Medicare budget, and general practice is pretty suspicious about that,’ Dr Djakic said.
‘If you have been seen in a public outpatient clinic, whether you’re private or not, there are meant to be no out of pocket costs – but that appears to fly.
‘And so the person that’s copping the administrative responsibility is the GP.’
To help GPs navigate the system, including conversations with patients, non-GP specialists and hospitals, the DoH has issued advice on the matter.
While GPs are not required to help patients decide on whether to be seen as a public or private patient, as many do, the department has included a breakdown on the differences between going public or private.
If a GP does discuss a patient’s preference to be public or private, it is suggested that the preference be recorded in the referral.
‘Patients can make a decision with you, or when they book the appointment, or when they attend the outpatient clinic,’ the DoH states.
‘If the patient is unsure, it may be best to provide a named referral – this will ensure the patient does not have to seek an additional referral before being seen, if they subsequently decide to be private.’
Dr Djakic, however, says that GPs do not necessarily have the time or resources to help patients navigate whether to go public or private, and says if the patient chooses to go private at a later date that it makes more sense for them to return to the practice for an updated referral.
‘Someone will turn around and say that will just harm and inconvenience the patient, and this and that,’ he said.
‘But we’re just being used as a doormat to facilitate someone else’s funding model – hospitals are going to be howling at our GP members for not toeing the line – and it’s not how the MBS referral pathway is written.
‘It shouldn’t be this difficult. It simply means we need to be moving to one health system and not eight.’
Detailed advice on named referral requirements and GPs’ role in supporting patient decision-making is available on the Department of Health website.
Members can also access responses to frequently asked questions about Medicare billing in public hospitals, as well as a Billing Medicare in Public Hospitals eLearning program.
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Dr John Anthony Crimmins   1/02/2022 7:49:24 AM

As a GP I am one of many that do not relaese my Propvider Number and write
This service does not comply with medicare

The College must represent the GP members in each state and raise this in each department of health-putting any conflicts aside.


Dr John Crimmins

Dr Diana Lorraine Hart, OAM   1/02/2022 8:00:34 AM

Most patients are not charged out of pocket expenses, it is just a mechanism for the hospitals to access extra money from Medicare rather than the total service being funded by the State government. We have now lost all our shared antenatal care in the Northern Beaches as they insist on named referrals. We are also not sent a letter from the specialists that we have been made to refer to, only the discharge summary once the baby is delivered if we are lucky! This is deskilling our GPS. It is time all health was under Federal to stop the cost shifting and duplication.

Dr Michael Charles Rice   1/02/2022 8:46:51 AM

I make most (not all) my initial referrals to the public hospital "to be treated as a private patient". Then I watch carefully.

My expectation is that "treated as a private patient" means being seen by a consultant specialist every visit. It means prompt and effective clinical handover - by the consultant. It means being treated by the same consultant for the majority of attendances. It means the patient knowing the consultant's name. THIS to me is "treated as a private patient"

"Informed financial consent" is weasel-words. "You can be seen for free as a public patient or bulk-billed as a private patient" Pffft. National Health Reform Agreement doesn't offer being billed as a private patient, or being funded from the Medicare pool from which the GP is tring to eke out a sustainable service too. NHRA offers to be "treated" as a private patient.

No "private" care = re-referral for default public treatment

Dr Chin Hian Lim   1/02/2022 10:36:46 AM

Yes I am glad eventually someone has started a conversation. The ridiculous referral for patients seeing the public system (quite often requiring a named specialist on the referring letter) is causing a huge problem for time poor GPs and an enormous economic burden on the country's health system. Especially at the present time when the country's health is under great strain in trying to cater for sick patients GPs are waiting precious consulting time just wiring referral letters for patients who are relatively healthy and do not require immediate medical attention. This rout is also seen ion the private sector where specialists are demanding referral letters when the subsequent visit is just over 12 months..
I am very keen to be involved in the discussion as I see this having an enormous negative impact on the ability of GPs to see sick patients (instead of writing meaningless and useless referrals) to satisfy "a system"

Dr Camilo Antonio Guerra   1/02/2022 1:10:44 PM

Lol! This has been going on for a while. I was called once by the OPD asking to send a referral right away as the patient was asked to see a different specialist for some undisclosed reason. I advised them that the duty on care was on their court and if there was a transfer of care it was the responsibility of the specialist not seeing the patient.

Dr Heather Knox   1/02/2022 9:06:53 PM

This has been happening for many years. However is now really the right time to be questioning how hospitals get their funding?

Dr Jacqueline Barry   3/02/2022 12:08:15 AM

This is standard operating procedure at my "local" hospital network, and has been for a number of years. Now, to reduce their waiting list for outpatient appointments, which in many cases are several years long, they are effectively removing everybody not referred in the last few months, requesting updated referrals to avoid removal from this list. Most cases are worse, and I haven't come across any that no longer need to be seen. They also seem to no longer be adding patients to surgical waiting lists without being seen in outpatients' clinic, even if the patient has been fully assessed by a specialist with admitting rights to the network. It's time this loophole was closed for good, and private patients seen in the consultants' private rooms.