Business Rules Applying To The Ambulatory Surgery Initiative
This Circular sets out the approved business rules applying to the Ambulatory Surgery Initiative (ASI) in public hospitals. Health Services and medical practitioners participating in the ASI must comply with the processes and procedures described in these business rules
1. Guidelines for suitability of procedures conducted under the ASI
The following criteria provide a guideline for determining the eligibility of procedures, which can be conducted under the ASI:
||Length of stay of several hours only|
||Performed under local or regional anaesthetic or light sedation|
||Associated with low risk|
||Associated with a rapid recovery|
||Has the capacity to have high volume throughput|
||Doesn’t require hospital doctor assistance|
||The relevant Medicare (non-inpatient) item number/s are available|
||Preferably have substantial waiting times, which require additional work to be done over and above standard lists|
||Potential for improved service delivery.|
Although the ASI is better suited to procedures performed under local anaesthesia or sedation that can be provided by clinicians, there is scope for some minor procedures that require general anaesthesia, or where there is a possibility it will be necessary to convert the local anaesthesia to a general anaesthesia, provided it is clinically safe to allow the patient to go home within a few hours post procedure. These procedures will require the additional services of a specialist anaesthetist or a suitably trained and credentialed GP anaesthetist.
- Patients must be privately referred by a doctor working in a private capacity to a named medical practitioner. A referral must not be made by a medical officer working in a public capacity at the time the referral is made. Clerical staff at each site or at the Central Wait List Bureau (CWLB) may facilitate this step.
- The referral letter is to be completed before the patient’s appointment.
- A hospital clerk or the private doctors’ rooms will contact patients and provide the option of having their procedure done under the ASI. The hospital clerk will also coordinate communication between the hospital performing the procedure and the CWLB.
- Patients must be willing to elect to be treated as private patients and must be provided with appropriate information in relation to their private election.
- Patients who unexpectedly require admission following their procedure, due to clinical complications, will be admitted according to the election of the patient for that unexpected admission.
- Patients who satisfy the conditions set out in the policy and who are treated as ASI patients are to be counted as additional work, not as public activity.
- If a patient presents and does not fulfil the conditions set out in this policy then alternative arrangements must be made for clinically appropriate care to be given outside of the ASI.
- Patients will be booked by hospitals as ASI patients. Hospitals will administer the bookings to provide ‘walk in / walk out’ lists for clinicians.
- Patients should be reminded to bring their Medicare Card to the ASI Clinic so as to avoid possible delays. Whilst not a requirement, it is recommended patients be asked to hand their Medicare card to clerical staff on arrival to be held at the reception desk until after the procedure. Patients should also be informed they will need to return to the reception desk prior to leaving in order to sign the Medicare voucher and pick up their Medicare card. Signage on the exits to this effect is also recommended.
- If a patient leaves without signing, the patient voucher should be printed and mailed to the patient for signing. Clerical processes need to be robust to ensure that patients do not leave without signing as billing cannot occur until the voucher is returned.
- At the completion of the consultation, the doctor must inform the clerical staff of the MBS item number to be used when directly billing the patient. This may be assisted by the use of pre-prepared checklists of standard procedures complete with Medicare item numbers.
- The Medicare card must be swiped through the reader or entered onto the billing software. The MBS code will then be entered and the patient voucher printed to enable the patient to sign.
- The patient cannot sign the Medicare voucher before the procedure, but must sign when leaving the non-inpatient clinic.
- The ASI recognises the private relationship between the clinician and the patient. Payment systems are available to allow clinicians to direct bill Medicare (ie accepting 85% of the Medicare schedule fee as full payment).
- At the time the appointment is made for a ASI procedure the patient is to be advised of the financial charges that will be made by the treating Medical practitioner and whether these are fully covered by Medicare.
- If a practitioner agrees to the bulk billing method, patients assign their right to a benefit to the practitioner as full payment for the medical service. An additional charge cannot be made for the service.
- It is a legal requirement that the assignment of benefit form be signed by the patient only after the service has been provided and the form completed. A copy of the completed assignment form must be given to the patient.
- The Medicare Benefits Schedule, available on the Department of Health and Ageing website at http://www9.health.gov.au/mbs/ provides detailed information on the arrangements applying to the payment of Medicare benefits for professional services rendered by registered medical practitioners. In the context of the ASI, particular attention is drawn to the requirements set out in the General Explanatory Notes, section 6 “Referral of Patients to Specialists or Consultant Physicians” and section 7 “Billing Procedures”.
- At the close of business of each day, transmission to Medicare Australia must be performed either by clerical staff or financial services, depending on the site, election and the type of system implemented.
- A weekly reconciliation of patients and MBS items is recommended to assess the process.
- Where electronic billing is in place there is no requirement to send hard copies of the vouchers to Medicare Australia. The vouchers must be stored for a period of two years prior to disposal.
5. Electronic Billing
Implementation of an electronic bulk billing system (Medicare Australia on-line) for processing Ambulatory Surgery Initiative related claims in public hospitals, requires the following:
Determine that the doctor has a provider number for the practice location (the hospital). If not, they must submit an application, and supporting certified documentation, to Medicare Australia at least twenty-eight (28) days before the proposed commencement date.
||If the doctor already has a registered provider number for the practice location, it is essential to check:|
||Whether they have nominated EFT bank payments to a bank account.|
||Whether they have nominated a Pay Group Link. |
Determine whether the doctor has elected to exercise their right to private practice (under the Industrial Agreement an election, once made, shall remain in force initially until the end of the financial year and thereafter, in accordance with the practitioner’s election, for each 12 month period).
Determine if the doctor is prepared to register to use Medicare Australia online. To register for Medicare Australia Online, the doctor will be required to submit contact details through the web based facility and to print, sign and return the Medicare Australia online Agreement to Health eSignature Authority Pty Ltd (HeSA).
Once HeSA has received and processed the doctor’s signed Medicare Australia Online Agreement, HeSA will notify the doctor that they have been registered for Medicare Australia Online.
During the completion of the Medicare Australia Online Registration process, practitioners will also have the opportunity to apply for their individual certificates with HeSA, if required.
Medical practitioners will also be required to complete and submit a Medicare Australia Online Banking Details form. This should be submitted with the signed Medicare Australia Online Agreement.
Practice locations/hospitals are also required to complete a Medicare Online Practice Details form prior to commencing online billing.
Transmission to Medicare Australia must be performed either by clerical or financial services staff depending on the site, election and the type of system implemented.
It is recommended that practitioners conduct a weekly reconciliation of patients with MBS payments received.
6. TOPAS Reporting Requirements
Changes to allow TOPAS to more effectively accommodate ASI requirements are scheduled to be commissioned in January 2006. Until these changes occur the standard practice following each ASI procedure is detailed below:
The patient episode is to be recorded in TOPAS using the Outpatient Module.
An outpatient referral should be generated using the referral source of PR (Private Referral) and the relevant private codes that are supplied by the CWLB The procedure must be entered in the Diagnosis block in the Outpatient Referral screen (selected from a local list of ASI procedures to be set up in Code Entry). It is essential that these processes be followed to enable accurate reporting of ASI activity.
7. Participating Medical Practitioners
It is the responsibility of each participating hospital to have robust credentialing systems in place for ASI consultants.
The practitioner and Hospital/Health Service must ensure that the criteria for treatment as an ASI patient are met.
Participating practitioners are able to access the Department of Health’s medical indemnity and protocol scheme covering patients treated under the initiative. The Protocol commits the State to provide support to medical practitioners working in the ASI in the event of a defined action by Medicare Australia.
Dr Neale Fong
DEPARTMENT OF HEALTH