|Title:||Business Rules Applying to the Privately Referred Non-Inpatient Service|
|Document ID:||Operational Directive OD 0466/13|
|Date of issue:||Thursday, 24 October 2013|
|Status:||NO LONGER APPLICABLE|
|Description:||The Operational Directive sets out the approved business rules applying to the Privately Referred Non-Inpatients (PRNI) services in public hospitals. Health Services and medical Consultants participating in the PRNI service must comply with the processes and procedures described in these business rules|
|Period of effect:||from 1 October 2013 to 1 October 2019|
|Authorised by:||Professor Bryant Stokes, Acting Director General, Office of the Director General, 15-Oct-2013|
|Print version:||View print version|
Business Rules Applying to the Privately Referred Non-Inpatient Service
This Operational Directive sets out the approved business rules applying to Privately Referred Non-Inpatients (PRNI) services in public hospitals. Health Services and Consultants participating in the PRNI service must comply with the processes and procedures described in these business rules.
1.1 Patients must be privately referred by a Consultant working in a private capacity to a named Consultant, and consent to being treated as a private patient. A referral must not be made by a medical officer working in a public capacity at the time the referral is made.
1.2 The referral letter is to be completed before the patient attends the hospital.
2.1 PRNI patients are private patients of the hospital. The treatment of PRNI patients (being private patients) is to be counted as additional work, not as public activity.
2.2 Patients will be booked by hospitals as PRNI patients. Hospitals will administer the bookings to provide ‘walk in / walk out’ lists for clinicians.
2.3 Appropriate information must be provided to patients in relation to their private election. This will include advice about the consequences of being a private patient and, in particular, the fact that when receiving medical services the patient will be a patient of the Consultant, not of the hospital (see also 3.7 - 3.9).
2.3 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.
2.4 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 PRNI.
3.1 Patients should be reminded to bring their Medicare Card to the PRNI 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.
3.2 Clerical processes need to be robust to ensure that patients do not leave without signing as billing cannot occur until the voucher is returned. If a patient leaves without signing, the patient voucher should be printed and mailed to the patient for signing and returning before submitting the benefit claim to Medicare.
3.3 At the completion of the consultation, the Consultant must inform the clerical staff of the MBS item number to be used when direct billing. This may be assisted by the use of pre-prepared checklists of standard procedures complete with Medicare item numbers.
3.4 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.
3.5 It is a legal requirement that the patient sign the assignment of benefit form only after the service has been provided and the form completed. A copy of the completed assignment form must be given to the patient.
3.6 If a patient is unable to sign the assignment form:
Where the signature space is either left blank or another person signs on the patient's behalf, the form must include:
3.7 The PRNI recognises the private relationship between the clinician and the patient. Payment systems are available to allow the Consultant to direct bill Medicare (ie accepting 85% of the Medicare schedule fee as full payment).
3.8 The patient is to be advised of the financial charges that will be made by the treating Consultant and whether these are fully covered by Medicare.
3.9 If the Consultant agrees to the bulk billing method, patients assign their right to a benefit to the Consultant as full payment for the medical service. An additional charge cannot be made for the service.
3.10 The Medicare Benefits Schedule (MBS) is available on the Department of Health and Ageing’s website (http://www9.health.gov.au/mbs/). The MBS provides detailed information on the arrangements applying to the payment of Medicare benefits for professional services. In particular, the attention of practitioners is drawn to the requirements set out in the MBS section G.6.1 “Referral of Patients to Specialists or Consultant Physicians” and section G.7.1 “Billing Procedures” and section G.12.1 "Professional Services”.
3.11 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.
3.12 A weekly reconciliation of patients and MBS items is recommended to assess the process.
3.13 If 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.
4. Participating Consultants
4.1 The Consultant and Hospital/Health Service must ensure that the criteria for treatment as a PRNI patient are met.
4.2 Payment arrangement and other relevant matters are set out in the “Medical Practitioners (Right of Private Practice – Non-Inpatient) Determination Number 1 of 2007”. That Determination is taken to form part of the Business Rules for the PRNI service (see http://www.health.wa.gov.au/indemnity/).
4.3 PRNI Consultants are eligible to apply for the Department of Health’s medical indemnity scheme covering patients treated under the PRNI service (see http://www.health.wa.gov.au/indemnity/).
4.4 PRNI Consultants will be supported and protected in the event of an investigation or inquiry into the service’s compliance with the Health Insurance Act 1973 (Cth). The specific support and protections are set out in the “Protocol Applying to Medical Practitioners Participating in the Ambulatory Surgery Initiative and/or the Privately Referred Non-Inpatients Model” (see Operational Circular OP 2074/06)
Professor Bryant Stokes
This circular last updated: Wednesday, 22 June 2016 at 10:25am