Surgical Assistant Billing Guide
6. Common Problems with Receiving Payments
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Overdue Accounts
If you bill your patients directly you are free to choose the terms of your accounts. However, you should bear in mind mail delivery delays and not choose an unrealistically close payment due date. Also, some patients will forward their account to Medicare and/or their health fund before paying you (despite what you may request of them), which will delay your payment by several weeks. Some doctors offer a discount if the account is paid by the due date as an incentive for prompt payment.
If you have billed directly to the health fund using their Gap Cover scheme you can expect a delay in payment of up to 8 weeks if lodging your account by mail, although you will receive most payments within 4 weeks. DVA and Workers' Compensation funds may have similar delays.
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Incorrect Payments
If you bill a patient using Gap Cover you may sometimes be paid a different amount to that which you have billed. Here are some reasons why this may happen:
- You have billed for the incorrect amount (i.e. above the maximum fee allowable)
- You have calculated your fee for a multiple-item-number operation but then not submitted all the item numbers on your invoice
- You have used different item number(s) to the surgeon
- The health fund has made an error
- Medicare has made an error
If you use EasyAssist to calculate your fees for Gap Cover billings you will drastically lower the chance of making an error in calculating your fee. You should only see errors if you accidentally choose the incorrect health fund, State/Territory or date of service. EasyAssist strives to be accurate to within 5 cents (due to different rounding practices by different health funds there is a 5 cent margin-of-error).
If you have received less than the amount specified by EasyAssist and you have: (a) checked that you have entered accurate information into the program, and (b) checked you have used the same item number(s) as the surgeon, then it is likely that either Medicare or the health fund has made an error. The health fund will handle correcting any errors made either by themselves or Medicare (called an 'adjustment') once they have found the source of the error.
If you are at fault and have submitted incorrect data you can still claim an adjustment by contacting the health fund concerned. If you undercharge a Gap Cover account, generally the health fund will not inform you of this fact and simply pay the amount you charged. However, if you discover your error they will pay the extra amount to which you are entitled after you submit an adjustment claim through them. The adjustment process differs between health funds; you should phone the individual fund for further details.
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Rejected Payments
There are many reasons why your claim may be rejected by a health fund when billing through Gap Cover, or by the DVA or Workers' Compensation insurer:
- You have submitted an incorrect assistant's item no.
- You have submitted an incorrect assistant's fee (above the maximum fee allowable)
- Your invoice contains incorrect information pertaining to the patient or the operation:
- Incorrect patient Medicare number, reference number or expiry date
- Incorrect patient name or date of birth
- Incorrect date of service
- Incorrect surgeon
- Different operation item numbers to that which the surgeon used
- The health fund or Medicare do not yet have a record of the operation taking place. This usually happens when the patient has not yet lodged a claim for the surgeon's bill, or the surgeon hasn't yet submitted his/her claim if using Gap Cover. In this instance the health fund and Medicare may have no record of the operation taking place and they will reject the assistant's claim.
- The patient is not eligible for Gap Cover
- Medicare or the health fund has made an error
Gap Cover payments are partly funded by Medicare and partly funded by the health insurance fund and both parties require certain information before they will process a claim (see Invoice Requirements for more details). If this information is missing or incorrect the claim will often be rejected. Similarly, because health funds send Gap Cover claims to Medicare on your behalf, an error created by one agency will propagate to the other and the claim will be rejected. You may receive only a cryptic message as to why there is a rejection on your claims statement.
In the event of a rejection, you should double-check all the information pertaining to the patient and operation. If you use EasyAssist it will be unlikely that you have the wrong assistant item number and fee. Check with the surgeon as to which item numbers they used on the patient's actual account (not the estimate of fees). If the patient is yet to submit their claim for a rebate for the surgeon's bill (and therefore the operation is unknown the health fund/Medicare) then you can ask the patient to submit their claim - often the surgeon's administrative staff can request this on your behalf.
If the source of the error is simple (wrong Medicare no., item no. etc.) then you can simply re-submit your invoice with the corrected information. If you believe the health fund or Medicare has made an error, you should contact the health fund in the first instance (or DVA or Workers' Comp. if applicable). If they claim the information produced by EasyAssist is incorrect, we would be interested in hearing about this. Please contact us with details and we will look into it.