Types of Claims
The most common claim types we can submit on your behalf are No Gap, Known Gap and Patient Accounts. It is your choice which one you will use on a patient by patient basis and we will submit claims according to your instructions. The differences between them are as follows:
1. No Gap Accounts
No Gap process:
- One account submitted directly to the Health Fund;
- The doctor charges the Commonwealth Medical Benefits Schedule (CMBS) fee, or
- The doctor and the Private Health Fund (either directly or via a private hospital) have an arrangement/agreement for payment above or at the CMBS fee and the doctor charges the agreed fee, e.g. Medical Purchaser Provider Agreement (MPPA); or
- The doctor uses an existing Private Health Fund ‘product’ (such as HCF’s Medicover Arrangement or NIB’s MediGap Scheme) and does not charge the patient an additional amount;
- Informed Financial Consent not required;
- No Gap claims are submitted directly to the Health Fund. The Health Fund forwards the claim eletronically to Medicare for 75% (of CMBS) in-patient benefits. The patient does not get any account making it a streamlined process with accounts being finalised by the Health Fund. We encourage No-Gap billing where possible for private patients as there is no out-of-pocket charge to the patient.
You will be paid:
- 75% of the CMBS fee from Medicare, and
- 25% of the CMBS fee from the Private Health Fund, and
- Any agreed premium above the CMBS fee from the Private Health Fund;
- No Gap accounts are paid in full by Health Fund/ Medicare at No Gap rate.
2. Known Gap Accounts
‘Known gap’ simplified medical billing occurs when the patient has a gap to pay and there has been an Informed Financial Consent process between the doctor and the patient.
Known Gap process:
- ‘Doctor Claim’ issues one account to the Health Fund, and the Health Fund submits the claim to Medicare for the 75% (of CMBS) in-patient benefit;
- A second account to the patient for the balance (i.e. the previously agreed ‘gap’ charge);
- Informed Financial Consent required.
You will be paid:
- 75% of the CMBS fee from Medicare, and
- 25% of the CMBS fee from the Private Health Fund, and
- any agreed amount above the CMBS fee from the Health Fund (if using medical gap schemes such as HBA’s Ezyclaim or Medibank Private’s GapCover); and
- the balance (i.e. the previously agreed ‘gap’ charge) from the patient. The co-payment is electronically deposited into your bank account depending on the time it takes to recover it from your patient.
Recovery of the agreed gap charge for Known Gap claims can sometimes be a slow process. If this is the process you prefer we recommend payment of your agreed gap charge to be collected up front from the patient prior to the service being provided.
Once we recover the agreed gap charge from your patient we will deposit it into your nominated bank account.
3. Compensation Related Claim
Should you have a compensation related claim to be submitted, such as:
- Third party MVA;
- Workers compensation;
- Personal injury or public liability;
- Medical negligence; and
- Dust diseases board.
Please be aware that these claims may be delayed due to the policy and procedures held by the individual Health Funds and Medicare.
Prior to submitting your inpatient medical claim details to ‘Doctor Claim’ we recommend that you obtain a copy of the approval letter issued by the Health Fund to the patient. For this letter to be issued your patient has to contact his/her Health Fund and initiate the process so the approval letter is issued to them.
This will ensure that in the future you do not receive a request to refund benefits to Medicare or the Health Fund.