Medical Billing in Australia is quite complex with various rules applied depending on:
- Invoice Type / Rate
- Private
- Bulk Bill
- DVA
- Insured
- WorkCover
- Medio Legal
- Benefit Level
- In Room / Out Patient
- In Hospital/ In Patient
- Provider Medical Discipline
- Provider's agreements with Health Funds
- Patient's type of insurance if any and level of cover
The DCM software is designed to assist in your understanding of the rules thus trying to eliminate errors and rejection of claims.
Detailed here are the rules as we best understand them. Up to you to know your own billing rules, so this is just a guide.
To ensure the Provider is setup correctly, go to Utilities - Entities
For actual use of DCM data entry for Transactions, go to articles in Use DCM Desktop - Regular Tasks - Clients - Transactions/IFC/Invoices/Private Invoices
To assist in your understanding based on your discipline, go to an article in Resources - Prepare for Private Practice.
- You can invoice whatever fee you wish for your services
- If you invoice a client with Private Health Fund insurance more than that fund allows, the rebate/benefit the client receives from the fund is reduced to 100% of the Medicare Schedule
- Medicare rebates 75% of their Medicare Schedule
- Health Fund tops up the 25% difference
- Client pays anything over this
Private Billing Rates in DCM are:
- Private
- Pension/HCC
- Custom Rate 1
- Custom Rate 2
- Custom Rate 3
The above show the Medicare Benefit / Rebate on the Invoice and IFC screen if selected to show and print on the IFC word document if selected to print.
If you want to use the Custom Rates, please email support@directcontrol.com.au to have them relabeled (e.g.: AMA)
The above can be transmitted to Medicare for the Patient Claim.
Other Private Billing Rates are:
- Uninsured
- Cosmetic
- Overseas
These have no benefit/rebate.
Uninsured is used by Hospitals for hospital billing for patients with no Private Insurance.
Manually send in claims to Health Funds, contact the health fund you are sending a direct invoice to for how to send this to them. Not Honeysuckle do not accept manual claims.
Health Funds that participate in ECLIPSE along with their functionality are found at http://www.humanservices.gov.au/health-professionals/services/simplified...
Not all do Online Eligibility Checks (OEC) nor receipt electronically (ERA) and some do not do both Medical or Hospital Claims. They also have a Participating/Fund Brand ID that needs to be maintained in Direct CONTROL. How?
ADF (Australian Defence Force)
- Managed by BUPA
- Fees are a percentage of the Medicare Fee but different percentage based on discipline
- No Out-Of-Pocket (OOP) allowed
- Does not ECLIPSE
AHSA (Australian Health Service Alliance)
- Go to www.ahsa.com.au to view Access Gap Cover Participating Fund List and other detail.
- Note The Doctors Health Fund has Premium Cover where the Fee Schedule is the AMA fee and not the AHSA fee so needs to be setup twice in Direct CONTROL. Once under the AHSA Group and once under the AMA Group
- Fees are a Scheme and vary per state
- Out-Of-Pocket (OOP) is allowed being no more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 20 working days
BUPA
- http://www.bupa.com.au/
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being no more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
CDH
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
DVA
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
GMHBA
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
HBF
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being no more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
-
Ensure in Contact Mangement - Insurers/Companies you have HBF allocated to the AHSA Fund Group. These are the fees they use for all states except WA
HCF
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
Latrobe Health
- Now part of AHSA
Medibank Private
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
Mildura District Health
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
NIB
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days
- Does not accept manual claims
St Lukes
- Fees are an Agreement
- Out-Of-Pocket (OOP) is allowed being nor more than $500 per invoice
- Does ECLIPSE
- Payment may take up to 10 working days