Getting Paid - Overview

Please click on the following links to explore the Surgeonline Getting Paid Overview:

  1. Introduction
  2. Medicare
  3. Private Health Funds
  4. WorkCover
  5. Motor Accident Authorities
  6. Department of Veterans' Affairs (DVA)
  7. Self-Funding Patients
  8. Procedures not Attracting a Medicare Rebate
  9. Gaps

1. Introduction:

The task of researching surgical billing within the private health system can be extremely frustrating and complicated for new surgeons and surgical assistants. This is because the calculation and distribution of your invoices will vary for each patient depending on:

The following section is designed to assist providers who are new to surgical billing with their understanding of:

This document is divided into sections, each referring to one of the many groups of Registered Health Benefits Organisations (RHBOs) that may be responsible for the payment of your invoices.

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2. Medicare:

Every Australian resident (and certain categories of visitors to Australia) is covered by Medicare for a certain percentage of their health related expenses, provided the medical service is considered to be "medically necessary".

"There are other services which are not regarded as being 'medical services' for the purposes of the payment of Medicare benefits. Services performed for cosmetic reasons, such as face lifts, eye-lid reduction, hair transplants (except in certain circumstances), etc do not attract benefits..."

Medicare Benefits Schedule Book -> General Explanatory Notes -> General Notes for Guidance of Users -> Services Which Do Not Attract Medicare Benefits

Each November (and then amended each May), the Department of Health and Ageing releases a Medicare Benefits Schedule Book which is an itemised list of all of the medical services that attract a Medicare rebate. Each service has a corresponding fee which is considered reasonable for that particular service.

"The fee for any item listed in the Schedule is that which is regarded as being reasonable on average for that service having regard to usual and reasonable variations in the time involved in performing the service on different occasions and to reasonable ranges of complexity and technical difficulty encountered..."

Medicare Benefits Schedule Book -> General Explanatory Notes -> General Notes for Guidance of Users -> Schedule Fees and Medicare Benefits

Category 3 of the Medicare Benefits Schedule Book - "Therapeutic procedures" is a similarly itemised list of all of the surgical operations (and corresponding fees) with which you may be involved. Some of these procedures will be marked with the word (Assist) in their description. This indicates that Medicare will pay benefits to surgical assistants for these procedures, as they are considered technically difficult enough to warrant an assistant.

"Items covering operations which are eligible for benefits for surgical assistance have been identified by the inclusion of the word "Assist." in the item description. Medicare benefits are not payable for surgical assistance associated with procedures which have not been so identified..."

Medicare Benefits Schedule Book -> General Medical Services -> Category 3 - Therapeutic Procedures -> Explanatory Notes -> Assistance at Operations

According to the Medicare Benefits Schedule, surgeons and surgical assistants will be paid an amount equal to 75% of the schedule fee by Medicare.

"With regard to medical expenses, the Medicare program is to provide for professional services rendered while hospital treatment (i.e. accommodation and nursing care) is provided to a patient who has been admitted to a hospital or day hospital facility (other than public patients), a flat rate of benefit of 75% of the Schedule fee, that is, there is no limit to the maximum amount of gap between the benefit and the Schedule fee..."

Medicare Benefits Schedule Book -> General Explanatory Notes -> General Notes for Guidance of Users

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3. Private Health Funds:

There are dozens of registered private health insurance agencies in Australia. Standard providers will generally receive the remaining 25% of the Medicare benefits schedule fee from the patient's health fund. Should you choose to charge more than the individual health fund's scheduled fee, the patient will be out of pocket. This is known as a "gap".

"Patients may insure with private health insurance organisations for the gap between the 75% Medicare benefit and the Schedule fee, or for amounts in excess of the Schedule fee where the patient has an arrangement with their health fund..."

Medicare Benefits Schedule Book -> General Explanatory Notes -> General Notes for Guidance of Users

Health Funds also now offer doctors the option of claiming Gap Scheme rebates. Registered Gap Scheme Providers are eligible to receive benefits well above the 100% Medicare Benefits Schedule fee without the patient being charged a gap. Percentages vary depending on the health fund and the procedures performed. This is discussed in more detail on the Getting Paid - Gap Schemes page.

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4. WorkCover:

Patients who are injured at work in Australia are protected by their state's WorkCover authority. A separate authority exists for each state in Australia, but each is responsible for regulating and enforcing the payment of benefits on behalf of patients who were injured at work.

Each year the WorkCover authorities release a schedule of fees which is considered a reasonable reimbursement rate for work-related medical expenses. Should you choose to charge more than the WorkCover schedule of fees, the patient will be out of pocket.

Depending on the state in which you are working and the patient's employer, you will be paid by either the patient's employer or the employer's insurance company. Medicare is not responsible for benefits relating to authorised WorkCover patients.

"Unless the Minister otherwise directs, Medicare benefits are not payable in respect of a professional service where:- (a) the service has been rendered by or on behalf of, or under an arrangement with, the Australian Government, a State or a local governing body or an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory; (b) the medical expenses were incurred by the employer of the person to whom the service was rendered; (c) the person to whom that service was rendered was employed in an industrial undertaking and that service was rendered to him/her for purposes connected with the operation of that undertaking..."

Medicare Benefits Schedule Book -> General Explanatory Notes -> General Notes for Guidance of Users -> Services Which Do Not Attract Medicare Benefits

In most states, the patient's employer is responsible for paying approximately the first $500 of medical expenses accrued. The employer's insurance agent is then responsible for paying the remaining expenses.

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5. Motor Accident Authorities:

Patients who are accidentally injured in a road transport accident in Australia are protected by their state's Motor Accident Authority. These authorities are state-run organisations which pay benefits on behalf of such patients or oversee the administration of claims via a third party insurer.

Each year these authorities release a schedule of fees which is considered a reasonable reimbursement rate for road accident related medical expenses. Should you choose to charge more than the recommended fee, the patient will be out of pocket.

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6. Department of Veterans' Affairs (DVA):

The Department of Veterans' Affairs (DVA) is a federally run organisation which pays benefits on behalf of veterans and their families.

DVA reimburses patients in the same way as private health funds (100% of MBS fees for standard providers and a higher percentage for "No-gap" providers).

Should you choose to charge more than the DVA scheduled fee, the patient will be out of pocket.

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7. Self-Funding Patients:

As mentioned previously, Medicare will pay 75% of the Medicare benefits schedule fee for services provided to an uninsured patient within an approved hospital facility. Should you choose to charge more than this, the patient will be out of pocket.

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8. Procedures not Attracting a Medicare Rebate:

There is a small number of procedures (cosmetic surgery for example) that do not attract a Medicare rebate. In this instance, surgeons bill patients directly and surgical assistants will need to make payment arrangements with the operating surgeon and/or the patient.

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9. Gaps:

Any amount you charge above the refundable limit is known as a "gap" and is paid by the patient. Surgeons and surgical assistants can legally charge a gap but will need to obtain informed financial consent from the patient beforehand. Surgical assistants should check in advance that their operating surgeon is happy for them to charge their patients a gap.

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