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GPs encouraged to report ‘double dipping’ hospitals
The advice comes amid reports of public hospitals mandating named referrals as a way of claiming MBS items.
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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