More changes in a nutshell

More Changes, Walnut

Loryn Einstein

Managing Director, Medical Billing Experts and Member of Association of Fraud Examiners

Loryn Einstein, Managing Director at Medical Billing Experts outlines the 2017 health fund and Medicare changes.

The sweeping changes we saw in the Medicare Benefits schedule in late 2016 were followed by several large shifts in the health funds in the first quarter of 2017.

The first three months of the year brought three new health funds to AHSA, changes in key disclosure policies by two health funds and a health fund merger. To keep your medical billing on track for 2017, here are a few things that you need to know:

  1. The merger of GMF and HBF 
  2. On 13 February 2017, GMF completed a merger with HBF that commenced in July 2015. All GMF members became HBF members as at the merger date. The date of the GMF merger with HBF coincided with the date that HBF joined the Australian Health Services Alliance (AHSA) for all states excluding Western Australia. 

    What this means for your billing: 

    • For all services provided to GMF members up to and including 12 February 2017, an invoice will need to be sent to GMF using the GMF member number. 
    • For all services provided to GMF members on and after 13 February 2017, the claim must be sent to HBF using the member numbers that HBF has now issued to the previous GMF members. For patients being treated on the cusp of this changeover, two invoices must be issued, an invoice for dates of service prior to 13 February to GMF and a separate invoice for dates of service including and after 13 February to HBF.


  3. HBF joins AHSA
  4. On 13 February 2017, HBF joined AHSA with the exception of services provided in Western Australia. The ability for providers to access benefits through AHSA in eligible states gives far greater flexibility in terms of gap restrictions. Whilst HBF prior to 13 February capped their known gaps to 10% over the HBF benefits schedule (before reverting to a benefit level of 100% of schedule fee), the AHSA gap rules are much more lenient. This can facilitate a reduced out of pocket amount for many patients.

    The AHSA Access Gap Medical arrangement also pays higher benefits to providers in most states than HBF pays for many item numbers crossing a broad range of specialties. The change made by HBF from an independent fund to a member of AHSA in NSW, ACT, TAS, VIC, QLD, SA and NT is a win for most providers. 

    What this means for your billing: 

    • From 13 February 2017 if you are a provider in any state other than WA, you will need to use the AHSA fund rates and billing rules when billing HBF patients. You will also have the benefit of the reduced out of pocket amount for patients which does give scope to build more positive relationships with them and will perhaps generate an increase in client numbers. 
    • Providers in WA will have no change in pricing schedules, gap arrangements or other billing arrangements with HBF. 


  5. AHSA announces two new health funds
  6. Two new health funds joined the AHSA in January.

    On 9 January 2017, Emergency Services Health joined AHSA. This fund is a restricted access fund offering health cover for people who work and volunteer with fire, state emergency, ambulance, medical response and recovery and water response and recovery sectors. 

    On 16 January 2017, Nurses and Midwives Health joined AHSA. This fund is exclusively for members of the nursing and midwifery communities and their families. 

    What this means for your billing: 

    • You need to add Emergency Services Health and Nurses and Midwives Health to your practice software. If you are already registered with AHSA, no further registration is needed as AHSA will automatically register you with Emergency Services Health and Nurses and Midwives Health. 


  7. AHSA makes major changes to provider information disclosure policy

    Starting from 1 January 2017, the AHSA Business Guidelines for doctors registered under its Access Gap Cover registration changed. From that date, any doctor submitting claims under the scheme (regardless of whether they registered with AHSA before or after 1 January 2017) will be subject to the new rules. 

    Under the terms of the updated AHSA Business Guidelines, any medical practitioner that submits a claim after 1 January 2017 automatically gives AHSA the right to: 

    • Publish the doctor’s name, practice address, speciality and other contact details on AHSA’s web-based doctor searches; and 
    • Publish information relating to the charges that doctors have rendered such as gaps that they have charged to patients who are members of any AHSA fund. 

    What this means for your billing: 

    If you submit any claim to AHSA after 1 January 2017, you are granting AHSA the right to publish information regarding all gaps you have charged to AHSA patients at any point in time, including dates prior to 1 January 2017. 

  8. Medibank and HCF increase disclosure of provider information 
  9. Medibank and HCF have also increased transparency of gap information. Both Medibank and HCF have partnered with leading Australian digital health information platform, Healthshare, to provide customers with more information to help with health decision making. 

    Specialists who have offered known or no out-of-pocket costs over the last 12 months will be listed on the website and app. Currently, Healthshare is accessible by around 85% of Australian GPs and it includes a platform where direct referrals can be generated. 

    The Healthshare partnerships with Medibank and HCF will give greater transparency of patient gaps to GP’s and patients which may impact referral patterns for GP’s towards no-gap providers. 

    What this means for your billing: 

    If you submit any claim to AHSA after 1 January 2017, you are granting AHSA the right to publish information regarding all gaps you have charged to AHSA patients at any point in time, including dates prior to 1 January 2017. 

  10. Changes to ePIP incentives 
  11. The Practice Incentives Program eHealth Incentives (ePIP) has been updated since my previous article in The Private Practice Magazine, with new targets and requirements. 

    What this means for your billing: 

    • The temporary amendment to ePIP requirements expired on 31 January 2017 and if your practice is registered now, you need to meet the shared health summary upload target in My Health Records each quarter to receive ePIP payments. 
    • Compliance activities are soon starting for all incentive payments paid to practices that did not meet their shared health summary targets for the first three quarters up to 31 January 2017. 
    • Updating your patient’s shared health summary when their medical circumstances change will assist in meeting your ePIP requirements. 


The Private Practice Magazine

This article featured in our
Winter 2017 Edition

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