Clients

Health Fund Registration

We have registered the provider numbers that you have supplied with Medicare and the health funds.

The Medicare forms will register your provider number against our Minor ID for billing using the Eclipse electronic system. This is necessary for processing DVA and Bulk Bill claims.

Registration with all health funds gives you the choice but not the obligation to use the various No Gap/Known Gap schemes that are offered. We will register you with each fund for the schemes that best suit your billing profile.

Medicare Guidelines

As part of the claiming process in Australia, before a health fund will accept a claim Medicare must first accept the claim. If Medicare will not pay a claim, then the health fund will not pay a claim.

No Gap, Known Gap, DVA and Bulk Bill claims are submitted electronically, using the Eclipse system. To be submitted electronically, the dates of service for claims must be less than two years old.

If you have billing that pre-dates joining Probills, please contact our office to discuss the options available to you and how we can assist. In some cases, health funds will allow backdating of registration, but this cannot be guaranteed. Billing that is two years or older will require specific consideration.

Process

We have provided you with template billing sheets upon which you should provide details of your patients and how you want us to bill them. Typically, attaching a hospital sticker will provide all the required patient details.  However, we can accept billing instructions in any format that suits your needs.

We suggest sending billing sheets regularly, at whichever interval suits you. Particularly for accounts to patients, we find that within a month of the surgery is an optimum time frame to ensure the best chance for full payment in good time.

Billing sheets can be forwarded to us by upload at the PBA Portal, email, fax, or via post. We will always send you an automatically generated email confirmation upon receipt of a batch of billing sheets.  Should you not receive a message confirming receipt, please contact us as your billing sheets may have not reached us.

Invoices are created with the information provided on the billing sheets. We will bill as you have indicated or per your agreed billing profile. Should this not be possible, or if there is some other problem, we will seek further instruction from you on a case-by-case basis. Our preferred method of communication in this situation is via email and we will respond to any email within one working day.

To help the process run smoothly:

• Please ensure that the hospital name is clearly marked on your billing sheets; not all hospital stickers list the name of the hospital, and many hospitals use the same style of sticker.
• Please ensure that the Medicare number and any health fund name and number is included for each patient, this is particularly important for Known and No Gap billing. If this information is not available to you, we will obtain it, but this may cause delays in processing your billing.
• Please ensure that any Workers Compensation and third party claims include details of the insurer, the claim number and the appropriate contact details. We will attempt to obtain this information if it is not provided; should we be unable to obtain the relevant information, we will forward the invoice directly to the patient with a request that they provide these details. This too can cause substantial delays in payment of the account.
• If sending the account directly to the patient our preference is via email. In our experience this is the most reliable method of establishing contact with patients. We would appreciate it if you can provide an email address for each patient. If no email address is available, invoices and receipts will be sent by Australia Post regular mail.

Our Daily Activity Report will be sent to you when your batch of billing is completed.  It details which patients and item numbers we have billed, the value of each account, and our fees to you. Any delayed billing will be listed so you can track its progress.

Expected turnaround for your billing in the office is two business days. As noted, ensuring that all relevant information is provided will assist in quick processing. Obtaining missing or additional information or clarifying instructions may cause delays.

Completed invoices are sent either electronically, if the payment is due from a health fund, DVA or Medicare; or by email or post to the patient, Workers Compensation or other third party insurer.

Payment for electronic claims (No Gap, DVA and Bulk Bill accounts) is made directly to your bank account; remittance advice is forwarded to us which allows us to monitor the progress of your accounts. Payments are generally very prompt and made according to the entities’ payment cycles.  We are advised of claims that have been rejected or underpaid and manage these through to conclusion. Claims that will not be paid are advised through Eclipse. There can be various causes of rejections; some of the most regular include membership issues, item number conflicts/restrictions or incorrect payments.

Patient accounts are paid directly to us. We offer your patients many options including internet or telephone credit card payment, electronic bank transfer, and payment by cheque. Patient credit card payments incur an additional 1.2% surcharge which is paid by the patient and retained by Probills.

Our Patient Liaison Team will manage all patient queries and will respond to patients within one working day. Any contact from patients that require your response will be forwarded to you the same day we receive it and we will respond on your behalf once an answer has been received.

There are instances where it will be necessary for us to arrange a refund to a party on your behalf. We will arrange the refund either by deduction from your weekly banking figures or seek reimbursement from you via tax invoice or by charging the credit card you have provided. We will contact you if the value of the refund is large or unexpected so there are no nasty surprises.

Payments received on your behalf are transferred to you on a weekly basis as part of our banking cycle.  Associated with this is our Weekly Activity Report that includes not only details of the payments we received but those that have been made to your account directly.

You can opt to receive our Practice Reports on a monthly, quarterly or annual basis. We have included your preference as per your application on your billing profile. Many reports are available on an ad hoc basis. Please contact our office if you would like more detail.

We bill you on either a weekly or monthly basis and payment terms are strictly 30 days.

We manage unpaid accounts with set reminders and phone calls. Details of any patient accounts that remain unpaid after term dates have expired and where we have sent all system-generated reminders will be sent to you for further instruction, allowing you to retain full control over your practice. Various options are available to you at that time which we are happy to discuss with you.

Payment periods for Workers Compensation and third party accounts are slightly longer–this is based on our experience in tracking payments. These are followed up to their conclusion. Should there be an issue with payment we will contact you for further instruction.

Estimates

We offer various Fee Estimate products:

• Your upcoming patients can contact us at any time with the specifics of their surgery and we will provide an estimate of your fees. An email of these details is sent to you at the time. For us to provide this we will need some guidelines from you in the form of either set fees for procedures or unit values.
• We can create a document for you based on fee information you have specified. This document can be provided to your surgeons so that it can be included in their information pack when surgery is booked. You can also hand it to patients yourself if it has not been possible for an estimate to be provided earlier.
• We have a Comprehensive Fee Estimate service; this is a formalised arrangement where we obtain list details from your specified surgeons and contact patients to advise them of your fees and inform them of their expected out-of-pocket amount. There is an additional fee per estimate for this service.

We can also provide privacy cards that you can give to patients; these inform the patient that ProBills will be provided with the information necessary to process their account.

Surgical Assistants

It is important that patients are aware of your involvement in their surgery and have been provided with an estimate of your fee. Typically, this will be provided by the surgeon in their information pack. If you are uncertain, please confirm the process with your surgeon’s rooms.

It is generally accepted that the assistant’s fee will be 20% of the surgeon’s fee if an invoice is being sent to a patient or third party. Any rebates paid by Medicare and health funds will be equivalent to 20% of the rebates paid for the surgical service. However, before any benefit can be paid for your service, the associated surgical item numbers must be claimed from Medicare.

Usually the surgical items are put on the record when the patient submits their surgeon’s invoice or receipt to Medicare. Even if your claim is going to be processed as a No Gap there can be a delay in payment when the patient has not submitted the surgeon’s account to Medicare. We will manage this process and follow up as appropriate with either your surgeon’s rooms or the patient directly.

Surgical Assistant fees are derived from the item numbers claimed by the surgeon. It is important that you provide the identical item numbers to those which the surgeon has used so that we create accounts that Medicare will accept and process quickly. Incorrect or incomplete numbers cause claims to be paid incorrectly, require additional follow-up and result in delays. These delays can be substantial if records require adjusting at Medicare.

It is important that you provide us with your surgeon’s details. Medicare need to make the connection between your claim and that of your surgeon’s. If there are multiple surgeons involved in one operation, we must understand your role–whether you assisted one or both surgeons-and have the correct item numbers specified for each surgeon.

Common Billing Terminology

To make things simpler we have compiled a list of some of the more common terms used in medical billing:

No Gap / MediGap / GapCover This is a scheme offered by all the health funds which means there is No out-of-pocket expense to the patient. Usually an electronic claim is submitted to the health fund. Payment is then made in accordance with MBS guidelines at fees from the fund schedule and paid directly to the provider’s account.

Known Gap / Access Gap Scheme This is a scheme offered by many of the health funds in which health funds will pay a higher benefit on behalf of the patient where the account fee meets the scheme criteria. These are usually a maximum out of pocket limit and that the doctor has obtained informed financial consent (IFC). This has the benefit of reducing patients’ gaps.

Co-Payment This is the out-of-pocket component of the Known Gap Scheme structure. Each health fund will allow a specified maximum gap. We can advise you on the specific requirements of these.

The Medicare Benefits Schedule (MBS) This is a listing of the Medicare services subsidised by the Australian Government. The so-called Schedule Fee is part of the wider Medicare Benefits Scheme managed by the Department of Health and Ageing (DoHA). It is important to understand that sending an account using Medicare item numbers is considered acceptance of the Medicare rules. Harsh penalties apply for claiming Medicare benefits in contravention of the Medicare rules.

Medicare Rebate This is the portion of the MBS fee that is paid by Medicare. For an inpatient service Medicare will pay 75%, the remaining 25% is paid by the private health insurer.

Australian Medical Association (AMA) The AMA publishes its own schedule of fees, which is reviewed and adjusted annually.  While there are many directly equivalent Medicare item numbers, some items, descriptors and restrictions can differ. We can explain this further on an as needs basis.

Uninsured patient This is a patient who does not hold eligible private health insurance. There can be many reasons for this. It is important that when electing to be treated as a private patient they are made aware that they are responsible for all associated costs. In particular, patients who are elderly, in poor health, or having major surgery should be made aware that their potential financial risk is unlimited, in the event of a complication involving intensive care admission or prolonged hospitalisation.

Private Patient This is a patient who has elected to be admitted to a private health facility or to be admitted as a private patient in a public facility. They are usually eligible for Medicare benefits and hold the appropriate level of private health insurance.

Overseas Patient They are usually either:

• Not Medicare eligible and have either Overseas Health Cover (OSHC) or Overseas Visitor cover with an Australian private health insurer. This will usually be a temporary resident, either for study or work, who holds an appropriate visa.
• Not Medicare eligible and hold cover with an overseas insurance company (such as travel insurance or corporate cover). This will usually be a tourist, or a person working temporarily in Australia who is covered by the business that is based overseas.

Medicare Only:

• a common term used within hospitals billing departments for a public patient or;
• an instruction to accept the 75% rebate from Medicare as full payment for services provided. This claim can be submitted electronically to Medicare.

Informed Financial Consent (IFC) This is the provision of information about fees to patients including likely rebates and possible reasons for any variation. Ideally this will occur prior to surgery and may be provided by the doctor, their staff, a party such as ProBills, or one of the other treating doctors (e.g. surgeons).  The patient should also be an active part of the IFC process and should be responsible for confirming the appropriateness of their health cover and rebates available from their fund. Good IFC process usually means a patient is more willing and able to pay their account. 

Fee Estimate This is part of the IFC process whereby the doctor will provide an estimate of their fee, the likely item numbers they will use and any expected out-of-pocket expenses. Ideally the estimate is provided in written form but may also be given verbally.

RFA This is a request for admission and comprises forms that contain patient information for upcoming surgery and are often sent by the referring surgeon, in place of a single surgical list document.

List This is a surgical bookings list which shows all patients intended for surgery on a particular day or session. Often sent by the referring surgeon for providing fee estimates, it typically details each patient’s procedure and insurance details.

Within Waits This refers to when a patient is still within health fund waiting periods. Patients commonly must serve a twelve-month waiting period after joining, or upgrading their level of cover, during which time their membership with the health fund is not fully active. Patients can complete forms that they send to the fund, to apply for payment while Within Waits. This often applies for emergency cases, or other unforeseen circumstances.

PEAs These are pre-existing ailment forms which health funds can require patients to complete when there are doubts about the provenance of a condition or if they are within their waiting period.