Surgical Assistant Billing Guide
Billing Using Gap Cover
Most Australian private health insurance funds provide an option for medical practitioners to use a Gap Cover scheme when obtaining fees for their services. The idea behind Gap Cover is to eliminate or reduce the amount a patient has to pay above the Medical Benefits Schedule (MBS) fee (known as a "gap payment"). Because Gap Cover payments are usually less than what many doctors would charge if they billed the patient directly, there is an administrative incentive for doctors to use Gap Cover (see below).
There are subtle differences between the Gap Cover schemes of different health funds, but for the majority the following is true:
- The account is sent directly to the health fund and not given to the patient (see 'Known Gap' Gap Cover below for an exception to this).
- The health fund collects Medicare's contribution to the doctor's fee, adds their own contribution, and pays the doctor the full amount via electronic funds transfer.
- Each health fund publishes its own Fee Schedule which lists the maximum amount payable per item number when using their Gap Cover scheme. Most health funds pay 20-50% above the Medicare Benefits Schedule fee for assistant item numbers.
- The accounts are sent to the health fund in a batch with an accompanying Batch Header form. Each health fund or health fund group has its own individual Batch Header form which you must use.
- The doctor must be registered with each health fund to use Gap Cover before they can claim Gap Cover accounts. This usually involves filling in a form available from the health fund or their website.
- Many health funds give their Gap Cover scheme a proprietary name, such as Medigap, Medicover and Access Gap Cover.
- Many small private health insurers belong to a group called the Australian Health Service Alliance (AHSA) and they share a common Batch Header form, available from the AHSA website. However, the claims are still sent to the individual funds.
'Known Gap' Gap Cover
Most funds now allow the doctor to charge the patient a co-payment while still claiming using Gap Cover - these funds have 'Known Gap' Gap Cover Schemes. These funds will pay the full Gap Cover amount to the doctor as long as any co-payment charged to the patient falls within their rules. The rules usually specify that informed financial consent must be obtained from the patient and there may also be limits on the amount of co-payment that can be charged. Some funds require doctors to nominate in advance whether they ever intend to charge patients a co-payment. These funds pay slightly lower Gap Cover fees to doctors that elect to charge co-payments, even if they only sometimes charge co-payments.
When charging a patient co-payment with a 'Known Gap' Gap Cover health fund, you must send an account to both the health fund and the patient. Usually you also indicate on the batch header that you are charging a patient co-payment.