|Title:||Business Rules Applying to the Ambulatory Surgery Initiative|
|Document ID:||Operational Directive OD 0467/13|
|Date of issue:||Thursday, 24 October 2013|
|Status:||NO LONGER APPLICABLE|
|Description:||The Operational Directive updates 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 set out in the 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, 03-Oct-2013|
|Print version:||View print version|
Business Rules Applying to the Ambulatory Surgery Initiative
The Operational Directive 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
1.1 The following criteria provide a guideline for determining the eligibility of procedures, which can be conducted under the ASI:
2.1 Patients must be privately referred by a doctor working in a private capacity to a named medical practitioner, 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.
2.2 The referral letter is to be completed before the patient attends the hospital.
3.1 ASI patients are private patients of the hospital. The treatment of ASI patients (being private patients) is to be counted as additional work, not as public activity.
3.2 A hospital clerk or the private doctors’ rooms will contact patients and provide the option of having their procedure done under the ASI.
3.3 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 doctor, not of the hospital (see also 4.7 - 4.9).
3.4 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.
3.5 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.
3.6 Patients will be booked by hospitals as ASI patients. Hospitals will administer the bookings to provide ‘walk in / walk out’ lists for clinicians.
3.7 ASI Waiting List(s) will be governed by the principles of the Elective Surgery Access Policy – Public and Private Patients (Operational Directive 0189/09 May 2009).
4.1 Patients should be reminded to bring their Medicare Card to the hospital 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.
4.2 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.
4.3 At the completion of the consultation, the doctor 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.
4.4 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.
4.5 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.
4.6 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:
4.7 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).
4.8 At the time the appointment is made for an ASI procedure the patient is to be advised of the financial charges that will be made by the treating doctor and whether these are fully covered by Medicare.
4.9 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.
4.10 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”.
4.11 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.
4.12 A weekly reconciliation of patients and MBS items is recommended to assess the process.
4.13 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.
5. Electronic Billing
5.1 Implementation of an electronic bulk billing system (Medicare Australia on-line) for processing Ambulatory Surgery Initiative related claims in public hospitals, requires the following:
5.1.1 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.
5.1.2 If the doctor already has a registered provider number for the practice location, it is essential to check:
i. Whether they have nominated EFT bank payments to a bank account.
5.1.3 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).
5.2 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.
5.3 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.
5.4 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.
5.5 Practice locations/hospitals are also required to complete a Medicare Online Practice Details form prior to commencing online billing.
5.6 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. MBS payments received.
6. Recording / Reporting Requirements
6.1 TOPAS HCARe webPAS (as applicable)
6.1.1 The patient episode is to be recorded using the Waitlist and ATD Modules.
6.1.2 The financial election of PR will be used for all ASI patients. TOPAS functionality prohibits the use of this financial election for any other admission. ASI cases will be isolated by the use of the financial election-type code for reporting purposes.
6.2 Activity Reporting
The WA Health Performance Reporting Branch is responsible for reporting on elective surgery cases performed under the ASI. Statistical information is included in the quarterly WA Health Performance Reports.
7. Participating Medical Practitioners
7.1 It is the responsibility of each participating hospital to have robust medical credentialing systems in place for ASI consultants.
7.2 The practitioner and Hospital/Health Service must ensure that the criteria for treatment as an ASI patient are met.
7.3 Participating practitioners are eligible to apply for the Department of Health’s medical indemnity scheme covering patients treated under the ASI (see DoH website http://www.health.wa.gov.au/indemnity/).
7.4 Medical practitioners participating in the ASI will be supported and protected in the event of an investigation or inquiry into the model’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)
 There is scope for some minor procedures that require general anaesthesia to be conducted under the ASI. Additionally, provided it is clinically safe to allow the patient to go home within a few hours post-procedure, the ASI can include procedures where there is a possibility of the need to convert the local anaesthesia to a general anaesthesia. These procedures will require the additional services of a specialist anaesthetist or a suitably trained and credentialed GP anaesthetist.
Professor Bryant Stokes
This circular last updated: Wednesday, 22 June 2016 at 10:22am