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Ongoing confusion over COVID vaccine billing


Anastasia Tsirtsakis


26/03/2021 4:23:32 PM

But the Federal Government’s stance is clear – patients should not be charged for vaccine-related consultations.

A patient at reception.
Reports have emerged of some practices charging patients for pre-vaccination appointments, violating the vaccination program’s requirements.

More than 126,000 doses of the Oxford University/AstraZeneca vaccine have already been administered under phase 1b of the rollout.
 
But as the number of general practices taking part increases, concerns have emerged around billing amid reports some patients have faced out of pocket costs for pre-vaccination appointments.
 
In Parliament on Thursday, Health Minister Greg Hunt said the cases were being investigated by the Department of Health (DoH), and that charging a patient any cost associated with the administration of the COVID-19 vaccine is ‘a breach’ of the program’s requirements.
 
‘There are three principles to the Australian vaccination program. Firstly, that it is free; secondly, that it is voluntary; and thirdly that it is universally available, with enough vaccine for every Australian three times over,’ he said.
 
The message was reiterated by Dr Lucas De Toca, Acting First Assistant Secretary for the DoH’s COVID-19 Primary Care Response, during a webinar for general practice on Thursday.
 
‘We have heard anecdotally … that in some instances patients, particularly not regular patients of a practice, are being required to conduct a pre-consultation health assessment or service, often co-paying, as a requirement before they can access the vaccine suitability assessment,’ he said.

‘That is not allowed because that is linking another service to the vaccine service and it’s creating a cost barrier to access the vaccine.’
 
As part of the onboarding package issued to practices taking part in the vaccine program, the DoH has included a fact sheet with guidelines for use of the 16 new Medicare Benefits Schedule (MBS) item numbers that cover costs of a vaccine suitability assessment: 

  • GPs in MMM1 areas (metropolitan centres) can claim the equivalent of a Level A attendance and a double bulk-billing incentive ($30.75) for the first vaccine suitability assessment service, and the equivalent of a Level A attendance and standard bulk-billing incentive ($24.25) for the second service
  • GPs in MMM2–7 areas (regional, rural, and remote areas) will receive $37.35 for the first service, and $27.55 for the second
  • practices that complete two vaccine suitability assessment services for the same patient in a clinically appropriate timeframe will be eligible for a $10 practice incentive payment, payable once per patient.
Separate MBS items have been created for after-hours services, adding an additional $12.15 onto each individual assessment service.
 
As bulk-billing incentives have been incorporated into the value of the new items, they cannot be co-claimed with items 10990, 10991 or 10992.
 
Dr Emil Djakic, GP and member of the RACGP Expert Committee – Funding and Health System Reform (REC–FHSR), told newsGP it is vital practices make patients aware that a separate appointment, prior to receiving the vaccine, is not necessary.
 
‘The process that we’re involved with includes the assessment of a patient for their eligibility … and safety for it, and the administration of the injection,’ he said.
 
‘If you’re having a conversation with the patient about the COVID-19 vaccine and you’ve got a vaccine in the fridge ready to give, and the patient chooses to proceed, then that’s an assessment done. The vaccine then gets administered by either that GP or the delegated appropriate registered practitioner.
 
‘If the patient chooses to not proceed with the vaccine, then that COVID-19 number can still be bulk billed.’
 
The suitability assessment can include a short patient history, limited examination and management, where clinically relevant, and then the vaccine is either administered or not.
 
If, however, the patient then chooses to come back at a later date, having decided to take the vaccine, Dr Djakic says the item number can be billed again.
 
‘Coming back later in the day on the same day, the Government’s still a little bit grey about, unless you can document extenuating circumstances, which is going to be a very, very small percentage,’ he said.
 
‘[But] if the patient chooses to come back next week and says “look, I’m thinking about it, I’m reconsidering doc”, then the GP can go through the same discussion, and then proceed to give the vaccine. They then bill that number again.’
 
If a patient presents with a separate clinical health issue during the vaccine suitability assessment, co-claiming of a separate item number is permitted. However, while the new MBS item numbers are not subject to the 80/20 rule, the co-claimed service is. 
 
‘If your patient in front of you is clearly struggling with an exacerbation of their asthma [for example] and you’ve just discussed the COVID vaccine and probably reached the conclusion to say, “today is not a good time to give you your COVID vaccine, I’d recommend you have it later” that’s a billable COVID vaccine assessment done,’ Dr Djakic said.
 
‘Now we need to treat their asthma. So you could raise the COVID number and then go on and raise a subsequent time-based item 23 or whatever, and if your private gap is part of that arrangement, then you can raise the private gap.’
 
Dr De Toca says the option for co-claiming also exists if a patient comes in for a non-vaccine related consultation and there is a chance to opportunistically vaccinate.
 
However, in both scenarios, he says the billing arrangements need to be communicated to the patient.
 
‘It needs to be clearly informed to the patient why that is happening and why they might be receiving a charge,’ Dr De Toca said.
 
‘We need to avoid at all costs a perception, real or perceived, that there is a charge for the vaccine service.’
 
Meanwhile, if a vaccine assessment service takes longer than expected, Dr De Toca said practices are not permitted to claim an additional COVID-19 MBS item number for a longer vaccine assessment.
 
The vaccine rollout is a significant undertaking alongside the day-to-day healthcare delivered by general practice, but Dr Djakic says the sector has the capacity.
 
‘It is a role that we’re fit for, trained for, and equipped for,’ he said.
 
‘It is a big block of additional work, there’s no denying that. But nobody invited this pandemic in and the solution that’s in front of us is one that we can all see ourselves signing up to. We just need to think our way through the solution we provide, which means ideally working efficiently and smartly to deliver.
 
‘Done that way, it delivers on a professional level for the general practice industry, it delivers on the quality and safety level for the patients who need this, and … it also, when run properly, fits with a business model that can be made to work and deliver appropriately.’
 
GPs can access the fact sheet on the MBS COVID-19 Vaccine Suitability Assessment Service, featuring example scenarios, on the DoH’S MBS website. A list of items, descriptors and rebates is available on the RACGP website.
 
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Dr Ross William Mowbray   27/03/2021 6:37:53 AM

Following a vaccination this week. we have had patients with adverse effects requiring further medical care including ECG and observation and treatment over the next hour. We claimed an extra item 36 bulk billed and medicare has initially rejected this and paid for ECG and covid consult.only. Medicare need to stop rejecting legitimate claims for service provided. The covid rebate is already inadequate for the giving the vaccinations.


Dr John David Laughlin   27/03/2021 11:21:20 PM

So help me with this one - I had a patient come in to discuss the vaccine with no other issues on his agenda. He basically wanted to tell me his concerns about the vaccine, that he wanted reassuring that it was not mandatory and that he was sure covid was created deliberately by the Chinese before going off down a rabbit hole of conspiracy theories. However, based on his age and comorbidities I would definitely assess him as suitable for vaccination (indeed he was happy to have influenza and Pneomococcus vaccination) but he did not want AZ vaccine nor did I have spare unallocated doses available to give him on the day should he have wanted it.
What am I supposed to bill medicare? Our practice bulk bills patients his age anyway so he had no out of pocket but if the same situation comes up for a privately billable patient, what to do?


Dr Rodney Paul Jones   28/03/2021 9:29:28 AM

What's the practical advice on MS patients? Especially where there exists a low risk of community acquisition of Covid
They need the stimulation of their inflammatory markers like a hole in the head.
Where is the trade-off?


Dr Peter JD Spafford   28/03/2021 9:07:40 PM

Wow, does the government really like to make things complex or what. And not pay reasonable amounts but insist on rates that are half of what they should be.