Your mixed billing questions answered

newsGP writers

7/06/2022 4:23:50 PM

Business sustainability has become a major issue for general practice, particularly following the Medicare freeze. Can mixed billing help?

Man paying over the counter for health services
Out-of-pockets costs for patients have grown significantly over the past decade.

In March, the RACGP hosted a webinar that focused on how to introduce mixed billing into general practice.
Presented by President Karen Price and facilitated by Chair of the RACGP Business Sustainability Working Group Dr Emil Djakic, it outlined the benefits of a mixed billing model and how to manage the transition to mixed billing, including discussing fees with patients.
Below are some of the standout queries from the final Q&A session.
Practice membership fees
Are we able to charge a practice membership fee and bulk bill members?
You cannot charge patients a fee if they are being bulk billed for a consultation. However, one way to incorporate a membership fee into your billing policy is to privately bill the first consultation with a patient each year, and then bulk bill any additional consultations. You could also privately bill more consultations if you like. See Case study 3 in the RACGP’s Billing case studies for an example of how this could work in practice.
Discussing fees with patients
Are there any examples of ways to have conversations with our patients to explain/justify charging a gap?
The RACGP has an information sheet which provides advice on how to communicate with patients about fees, including tips for engaging in conversations about why patients are being charged a gap fee or why their fees have increased.
Many patients are starting to recognise the value of the care they receive from their GP, particularly as GPs have been there for their patients during the COVID-19 pandemic and their doors have stayed open. Patients have also valued the flexibility that telehealth consultations provide. The amount that people pay for general practice care compared to other health services is quite small. Patients who are paying out-of-pocket costs often don’t see this as a problem if they feel they are receiving value for money.
Gap fees
Is there any way for the patient to only pay the gap rather than pay the whole amount and then have to claim back from Medicare?
Unlike other forms of health insurance, current legislation prevents patients from paying the difference between their benefit (patient rebate) and the total fee for the service. Instead, privately billed patients are required to pay the whole fee and subsequently obtain reimbursement for their benefit from Medicare. The Health Insurance Act 1973 provides the legislative framework for the payment of Medicare benefits.
The RACGP recognises that only being required to pay the gap amount would make it easier for patients to afford fees. We have written to the Department of Health to express concern about the continued operation of the 90 day pay doctor cheque scheme. We understand the federal government plans to phase out the cheque system by July 2023.
The RACGP recommends the system be abolished by 1 July 2022, allowing GPs to be paid immediately via Electronic Funds Transfer (EFT) even if the account has not been settled in full. This archaic system is an added administrative and financial burden that GPs and patients simply do not need, particularly during a pandemic.
Unfortunately, there are no plans currently to phase out cheques before 2023 or remove the 90-day timeframe, as the government sees this as supporting bulk billing. This is because if a patient is unable to pay the full amount on the day of the consultation (rebate + gap fee), the GP could be left waiting up to 90 days to be paid. In that case the GP may choose to bulk bill the patient as a one-off.
The RACGP will continue to advocate where possible for this scheme to be reviewed.
It is important that practices clearly advertise their fee policy so that patients understand the need to pay in full on the day of the consultation.
Managing competing views on billing
What if different practitioners in the practice have different views on bulk billing? How do we handle that if one doctor wants to implement mixed billing?
If you are an independent contractor rather than a salaried employee, you should be free to determine your own billing policy, even if other doctors in your practice exclusively bulk bill.
If you are experiencing backlash from other doctors, talk to the practice owner/s about your intention to move away from bulk billing and your rationale for this.
The issue of employee contracts can be complex. GPs and practices should seek legal advice relevant to their situation if they are unsure if they or an individual is an employee or a contractor.
The RACGP’s General Practice Business Toolkit provides some information on the difference between an employee and a contractor in Module 5 – Your practice team. The Fair Work Ombudsman, and the Australian Taxation Office also provide advice about the differences between employees and contractors.
It is important to remember that billing is a personal choice. If you have strong views on mixed billing but other doctors in your practice don’t feel the same way, they are not obligated to follow your direction and change the way they bill.
GPs who see a high proportion of vulnerable patients may be particularly reluctant to change their billing policy. However, the RACGP does encourage all members to think about your billing policy and whether it is sufficient to cover your increasing practice costs, as well as achieve an optimal work-life balance. Your RACGP membership gives access to a range of resources to help you manage your billing.
GPs want to do the right thing by their patients, but it is becoming increasingly difficult to sustain a successful general practice by bulk billing. We need to show our politicians that primary healthcare needs greater government investment, particularly to support patients who need longer consultations for more complex care.
Corporate practices
Competing with corporate owned medical centres that bulk bill is difficult for small practices. Can our college lobby the government to stop these giants from eating up smaller practices? Shouldn’t we as a GP group cooperate to fight this type of bulk billing?
The RACGP does not have a position on corporate general practice. Our focus is on ensuring members are properly equipped to deal with funding constraints and manage their finances accordingly. Encouraging more GPs to privately bill (where appropriate) without fearing the implications is also a key priority.
Research suggests the trend towards larger corporate owned general practices may affect access and quality of patient care, however there is considerable debate about the impact of corporate practices. The RACGP recognises that our members work in a variety of settings, including corporates. If you work for a corporate practice and are an independent contractor rather than a salaried employee, you should be free to determine your own billing policy, even if other doctors in the practice bulk bill.
Universal mixed/private billing
Should we find a way for all GPs to unite and start applying fees at the same time or on the same day?
The RACGP’s position is that billing is a personal choice and there are many circumstances that can influence how a GP bills. We do not support a shift to mandatory mixed billing due to the potential impact on vulnerable patients.
We do not currently have plans to encourage a universal shift towards private billing, including for a set period (eg privately billing all patients for a day/week).
Billing trends/data
What change to the bulk billing rate will be needed to get the federal government to take any notice?
The RACGP believes the government will take notice of any reduction in the bulk billing rate, however it is likely that a consistent trend in reduced bulk billing will need to emerge to prompt action on primary care funding.
Member support
We would like to get support from the RACGP to have a team to support and address our billing issues and questions.
The Funding and Health System Reform team, which sits within the Policy and Advocacy business unit, is best placed to assist with queries about billing. You can contact the team via and they will do their best to assist.
Members also have the option of joining RACGP Specific Interests Business of General Practice. For more information, contact RACGP Specific Interests via
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Dr Graham James Lovell   8/06/2022 8:32:45 AM

The reality is that bulk billing Corporates mesh perfectly with rapid throughput general practice consultations causing the continuation of high bulk billing rates .
This thereby allowing the Federal Government to achieve the massive cost savings to them of Medicare freezes and reduced CPI increases.
If you want a viable practice on $39 + incentive for a standard consult when CPI increases true value is now $86 (as per AMA )“you’re dreaming “.
And then being expected to carry the debt to you for 90 days!
Seriously -you will work yourself into the ground, and then the patients will just find someone else when you do.

Dr Ronald Campbell   8/06/2022 6:18:16 PM

Medicine should have adopted the same approach Pharmacy has, i.e. only a doctor could be allowed to own a medical practice. Allowing Corporates and other non medically trained owners into the picture has created 5 minute medicine and taken away the prestige of ownership, and profits have become the main focus rather than good clinical care. It has also not done much to promote GP to medical graduates and weakened the political position of Medicine. The Pharmacy Guild seems to have more political influence given its in-house ownership. If you work in an area where there are multiple bulk billing practices, none owned by doctors, then there will be little joy in trying to introduce private billing.

Dr Arlene Nicol Suttar   11/06/2022 10:12:01 AM

GP trainees need a business unit in their training as most are from well off professional families who have not run a business on tight margins (( a minority are not ), so they have no natural exposure to the realities of business...wages, superannuation , leave loading , long service leave and parental leave provisions , insurance , building maintenance , heating rates etc
Also , the gap payment argument is a none argument nowadays . With eftpos, and patient consent to linking with medicare our patients are refunded the medicare component of billings at the counter before they leave, so should they whinge ,it is about a $25-$40 cost . I can handle that diplomatically.