Overview
Patients need to have in place:
o A GP Management Plan AND Team
Care Arrangements (items 721 and 723); OR
o An EPC multidisciplinary care
plan (items 720, 722, 730 or 731). GPs need to use an EPC Program referral form
for allied health services under Medicare to refer patient.
Port
Hacking Osteopathic Clinic is registered with Medicare Australia.
Maximum
of 5 services per patient per calendar year.
Talk to us about this new option when you come in for treatment or by calling
us on (02) 9540 1833
What are the allied health
Medicare items?
There is an MBS item for Osteiopathic health services
requested by a GP on an EPC Program referral form:
Item 10966 - services provided
by an Osteopath
Osteopathic professionals may set their own fees. However
for each item, the Medicare schedule fee is $53.90, with a Medicare rebate of
$45.85.
Conditions for claiming the items
The items can
only be claimed where all of the following conditions are met:
(a) the service
is provided by an allied health professional registered with Medicare Australia
for this initiative;
(b) the service is provided on referral from a medical
practitioner (including a general practitioner but not including a specialist
or consultant physician);
(c) the service is specified in an EPC allied health
referral form;
(d) the person is being managed under an EPC plan;
(e)
the person is not an admitted patient of a hospital or day-hospital facility;
(f) the service provided is of at least 20 minutes duration, to an individual
patient, in person;
(g) the allied health professional has provided a written
report on the service to the referring practitioner (NOTE: where the allied health
professional has provided more than one service to a patient under the same referral
from the referring practitioner, the allied health professional is required to
provide a written report to the referring practitioner on the first and last service
only, and more often if clinically relevant);
(h) the person has not received
more than 5 services to which items 10950-10970 apply, in a calendar year; and
(i) the service has not been funded through other State or Commonwealth programs
(see Other publicly funded programs).
What information
is required in the report to the GP?
Allied health professionals should
provide the referring GP with information about, eg:
o any investigations,
tests, and/or assessments carried out on the patient;
o any treatment provided;
and
o future management of the patient's condition or problem.
Is
it necessary for the GP to use the referral form?
Yes, GPs are required
to use the referral form. However, signed copies of the form no longer need to
accompany Medicare claims.
The format of the form may be modified to suit
practice software needs. However, its content must remain substantially the same
as the original Department of Health and Ageing form. A Microsoft Word version
of the form is available at the Department's website: www.health.gov.au/strengtheningmedicare.
If
GPs are concerned about the appropriateness of format and/or minor content changes,
they may fax copies of modified forms to the Department's EPC and Allied Health
Section on (02) 6289 7120 for approval.
Do patients need to obtain
a new referral for these services every 12 months?
Yes, where patients
wish to access Medicare rebates for services recommended in their EPC plan during
their next period of eligibility (that is, the next calendar year), they should
see their GP to obtain new referral forms.
The referral remains valid for
the stated number of services. If the services are not used during the calendar
year in which the patient was referred, the unused services may be used in the
next calendar year. However, they will be counted as part of the five rebates
for allied health services available to the patient during that calendar year
(that is, the maximum number of rebates a patient can access in a calendar is
five regardless of how many were accessed the previous year).
GPs may choose
to use this visit to undertake a review of the patient's EPC plan where appropriate,
or to manage the process using a GP consultation item, depending on the patient's
circumstances and needs.
NOTE: It is not necessary to have a new EPC plan
prepared every 12 months just to access a new set of allied health referrals.
Patients continue to be eligible for rebates for eligible allied health services
while they are being managed under an EPC plan, as long as the need for the eligible
services continues to be recommended in their plan.
How
do patients get a rebate for these services?
When the allied health
professional has provided the service s/he may then:
1. seek payment for
the service from the patient. The patient then takes the itemised receipt from
the allied health professional to Medicare to claim the Medicare rebate. Out of
pocket costs will count toward the Medicare safety net; or
2. seek payment
for the service directly from Medicare. The patient must first sign an assignment
of benefit form and the allied health professional will send that to Medicare
for payment. To claim direct payment from Medicare in this way, the allied health
professional accepts the value of the Medicare rebate in full payment for the
service and will not be able to charge the patient a gap.
The
following information must be shown on patients' itemised accounts/receipts:
o
patient's name and date of service;
o MBS item number and/or description
of service;
o name and practice address or name and provider number of servicing
allied health professional;
o name and practice address or name and provider
number of referring GP and date of referral; and
o amount charged, total
amount paid, and any amount outstanding in relation to the service. Note:
Before a rebate can be paid for the allied health service provided on referral
from a GP, either the patient must have already claimed a rebate, or the GP must
have already lodged a claim for direct payment from Medicare for the relevant
EPC planning item(s). Allied health professionals may wish
to check their responsibilities for Medicare claiming and payment processes with
Medicare Australia on 132 150.
A copy of the
MBS booklet Medicare Benefits for allied health and dental care services provided
to people with chronic conditions and complex care needs is sent to all registered
allied health professionals. Updated annually, it contains item descriptors and
explanatory notes including information on billing and claiming the items.
Alternatively
the Medicare Australia website: www.medicareaustralia.gov.au
is a useful resource.
What about patients with
private health insurance cover?
Patients need to decide if they will
use Medicare or their private health insurance ancillary cover to pay for these
services.
Patients with such insurance can either:
1. access rebates
from Medicare under the allied health items by following the claiming processes;
or
2. see allied health professionals of their choice and claim on their
insurance's ancillary benefits. No referral form is required in this case. Patients
cannot use their private health insurance ancillary cover to 'top up' the Medicare
rebate.
It is important for patients to check with their health fund which
ancillary services are covered and what their out of pocket expenses are likely
to be.
Other publicly funded programs
Allied
health services funded by other Commonwealth or State programs are not eligible
for Medicare rebates. Examples include State government hospital outpatient clinics,
the More Allied Health Services (MAHS) program, Commonwealth Hearing Services
Scheme or Department of Veterans' Affairs services for veterans.
Where an
exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted
to an Aboriginal Community Controlled Health Service or State/Territory clinic,
the allied health items can be claimed for services provided by eligible allied
health professionals salaried by, or contracted to, the service.
Example
of the how the Medicare allied health items work
The GP completes
a GP Management Plan (GPMP), coordinates Team Care Arrangements (TCA) and bills
the relevant EPC CDM items for Ms Jones.
In finalising her TCA, the GP refers
her to an eligible podiatrist for 5 services using the 'EPC referral form for
allied health services under Medicare'. This enables her to access Medicare rebates
for eligible podiatry services recommended under her TCA.
Ms Jones takes the
form to the podiatrist who must retain it for Medicare Australia auditing purposes.
The podiatrist provides Ms Jones with her first service.
If Ms Jones' podiatrist
accepts the value of the Medicare rebate as full payment for this service, s/he
will not be able to charge Ms Jones a gap. Ms Jones must first sign an assignment
of benefit form and the podiatrist will send that to Medicare for payment.
If
the podiatrist charges a fee higher than the Medicare rebate and Ms Jones elects
to pay the full amount up front, she will then need to take/send the itemised
receipt from the podiatrist to Medicare to claim the Medicare rebate and have
her out of pocket costs counted toward the Medicare safety net.
This billing/claiming
process is repeated for Ms Jones's 4 subsequent visits under the same referral.
For more information call
Medicare Australia on 132 150 or go to www.medicareaustralia.gov.au
About
Our Practice
About Osteopathy
Port
Hacking Osteopathic Clinic 
