St. Luke s Gap Cover Information for Medical Practitioners

Transcription

1 St. Luke s Gap Cover Information for Medical Practitioners Closing the gap in private health care. r health your health fund your health your health fund your health your health fund your health your health fund your health Updated January 2008

2 INTRODUCTION What is St. Luke s Gap Cover? What are the advantages for medical practitioners? Page 1 1 OPERATING GUIDELINES What do I need to do for my patients to receive St. Luke s Gap Cover Benefit? St. Luke s Gap Cover benefit Patient Relationship Informed Financial Consent and Financial Disclosure How are claims made? How will I be paid? Customer Service Listing of Participating Providers Enquiry Support and Stationery Supplies APPENDICES St. Luke s Gap Cover Request Form EFT Payment Form Request for Customer Service Listing Stationery Order Form Batch Summary (Sample) Estimate of Medical Fees (Sample)

3 Introduction WHAT IS ST. LUKE S GAP COVER? St. Luke s Gap Cover is a medical gap cover arrangement that is designed to provide Medical Practitioners with the option of eliminating or reducing the medical gap for eligible St.LukesHealth members requiring hospital in-patient medical services. St. Luke s Gap Cover allows the Fund to pay an additional gap cover benefit, over and above the Medicare Benefits Schedule Fee to eligible members receiving in-hospital medical treatment from a participating Medical Practitioner. A Medical Practitioner can participate in the St. Luke s Gap Cover arrangement as a No Gap Participating Provider or a Known Gap Participating Provider. St. Luke s Gap Cover also provides the choice to opt in or out of the arrangement at any time on a patient by patient basis. St.LukesHealth members eligible for St. Luke s Gap Cover will receive the higher medical gap benefit for in-hospital medical services providing the following requirements are met: WHAT ARE THE ADVANTAGES FOR MEDICAL PRACTITIONERS? St. Luke s Gap Cover provides a No Gap and a Known Gap option. Your patient will receive a higher benefit for the services provided by you. The St. Luke s Gap Cover Schedule of Fees is reviewed and indexed annually. The claiming process is streamlined, therefore improving your accounts administration and cash flow whilst providing greater convenience for patients. Online claiming of Medicare and Fund benefit is available through ECLIPSE. Quicker processing time means faster payment of accounts. The incidence of bad debts and the expense involved in collecting those debts can be reduced. You have the choice of being included on a Customer Service Listing of Participating Providers. Patient accounts are sent direct to the Fund for the processing of Medicare and Fund benefit in accordance with the Billing and Claiming Guidelines of St. Luke s Gap Cover; Informed financial consent is obtained from the patient in writing prior to the treatment or in the case of emergency treatment, as soon after treatment as practical where a known gap applies; The patient is informed of any financial interests you may have in any product or service recommended or given to the patient; and The fee charged for each item on the account is in accordance with the No Gap or Known Gap levels provided for within St. Luke s Gap Cover. Full detail of St. Luke s Gap Cover, is contained within this handbook. A Billing and Claiming Guide is also included with full details on the billing and claiming processes available under St. Luke s Gap Cover. st.lukes GAP cover - information for medical practitioners 1

4 Operating guidelines WHAT DO I NEED TO DO FOR MY PATIENT TO RECEIVE ST. LUKE S GAP COVER BENEFIT? 1. Complete the St. Luke s Gap Cover Request Form included in the Appendices and send it to St.LukesHealth together with your stationery order. 2. Complete the EFT Payment Form and return it to St.LukesHealth if you require benefit payments to be credited directly into your nominated bank account, otherwise, benefit will be paid by cheque. 3. Where a known gap applies, obtain written informed financial consent from your patients prior to treatment or in the case of emergency treatment, as soon after treatment as practical. For more information on Informed Financial Consent see the section headed Informed Financial Consent and Financial Disclosure on page Inform each patient of any financial interest you may have in any product or service being recommended or given. 5. Ensure your fee charged for each service provided is in accordance with the No Gap or Known Gap levels provided for within St. Luke s Gap Cover. 6. Send your accounts direct to St.LukesHealth using the St. Luke s Gap Cover Batch Summary or submit your claims online through ECLIPSE. For more information on ECLIPSE see the St. Luke s Gap Cover Billing and Claiming Guide available from our web site at No Gap Services To ensure your patient is fully covered for the service they are receiving, your fee charged should not exceed the St. Luke s Gap Cover Schedule Fee. The St. Luke s Gap Cover Schedule of Fees is available from our web site at Known Gap Services If you wish to charge a known gap to eligible St.LukesHealth members, St. Luke s Gap Cover benefit will only apply if the known gap for each service is within 10% of the St. Luke s Gap Cover Schedule of Fees. Eligible St.LukesHealth members using a Known Gap Participating Provider will have a maximum out-ofpocket contribution of 10% of the St. Luke s Gap Cover Schedule Fee per service rendered by that provider. The patient should be direct billed for the 10% Known Gap amount after the service has been rendered. The patient should also be informed that the Known Gap amount is not claimable from any other source. The fee shown on the account sent to St.LukesHealth should be the full fee and should include any known gap charged to the patient. Informed financial consent must be obtained from the patient where a known gap is charged. ST. LUKE S GAP COVER BENEFIT The St. Luke s Gap Cover benefit is identified and defined by the Commonwealth MBS item number. The benefits payable for an eligible service will be in accordance with the St. Luke s Gap Cover Schedule of Fees. The benefit is inclusive of the Medicare rebate, the 25% medical gap benefit and the additional St. Luke s Gap Cover benefit. The Schedule of Fees is reviewed and indexed annually on 1st December. All assessing rules applying to Medicare rebates will also apply to benefits paid under St. Luke s Gap Cover. The St. Luke s Gap Cover Schedule of Fees is available from our web site at PATIENT RELATIONSHIP St.LukesHealth acknowledges that it is for each Medical Practitioner to exercise their own clinical judgement at all times in relation to the provision of services to eligible St.LukesHealth members. St.LukesHealth further acknowledges that it will not interfere in the autonomous relationship between the Medical Practitioner and their patient. 2 st.lukes GAP cover - information for medical practitioners

5 INFORMED FINANCIAL CONSENT AND FINANCIAL DISCLOSURE Informed Financial Consent Informed financial consent should be obtained prior to treatment or, in the case of emergency treatment, as soon after treatment as practical. You may not charge any fee to your patient such as a Booking Fee or Hospital Facility Fee or similar. The Department of Health and Ageing in consultation with the AMA and other relevant industry bodies has developed an Estimate of Medical Fees form, which has been designed to assist you to provide written Informed Financial Consent. A sample of the Estimate of Medical Fees form is included in the Appendices. A template of this form can be provided if required. Financial Disclosure You should also disclose any financial interest you may have in any product or service recommended or given to your patient. This information can be provided to the patient on the Estimate of Medical Fees form. HOW ARE CLAIMS MADE? St. Luke s Gap Cover provides a simplified billing option where accounts are submitted directly to the Fund either electronically or by mail for the payment of Medicare and Fund benefit. The claiming procedure is summarised below. Billing the fund direct by mail or electronically through ECLIPSE 1. Confirm that the patient is a member of St.LukesHealth and holds private hospital cover. 2. Obtain the patient s St.LukesHealth membership number, Medicare number and Medicare card reference number. 3. Obtain informed financial consent in writing from the patient if a patient contribution or known gap is being charged and provide financial disclosure by using the Estimate of Medical Fees form or similar. A sample of an appropriate Estimate of Medical Fees form is included in the Appendices. 4. Ensure your fee charged is within the allowable limits of St. Luke s Gap Cover. 5. Bundle your accounts, complete a Batch Summary and send your claims batch direct to St.LukesHealth. A sample copy of the Batch Summary is included in the appendices, or 6. Submit your accounts electronically through your practice management software using the ECLIPSE functionality. For more information on ECLIPSE see the St. Luke s Gap Cover Billing and Claiming Guide. A complete guide to the claiming process is available in the St. Luke s Gap Cover Billing and Claiming Guide available from our web site at HOW WILL I BE PAID? Payments can be made by Electronic Funds Transfer (EFT) direct to your nominated bank account usually within 21 calendar days of receipt of the patient s claim, providing Medicare payment has been received by the Fund. You will need to supply St.LukesHealth with your banking details on the EFT Payment Form included in the Appendices if you wish to be paid by Electronic Funds Transfer. If bank account details are not provided payment will be made by cheque. St.LukesHealth will forward payment for each account as soon as assessment is complete regardless of the processing status of other accounts submitted within the same batch. Statement of Benefit A Statement of Benefit will be posted to you at the time payment is made by EFT (in the case of cheque payment, the statement will accompany the cheque). Please allow approximately 3 working days for receipt of the statement after payment by EFT. The Statement of Benefit will detail payments and rejections together with assessment/rejection explanations. st.lukes GAP cover - information for medical practitioners 3

6 Operating guidelines (cont d) A Statement of Benefit will also be sent to the patient detailing the benefit payment and any known gap that applies. CUSTOMER SERVICE LISTING OF PARTICIPATING PROVIDERS You may request to be included on a customer service listing of No Gap and Known Gap Participating Providers. The listing is available to St.LukesHealth members from any St.LukesHealth office and from our web site at Inclusion on the list is optional, however if you do wish to be included it is an indication that you will be participating in the St. Luke s Gap Cover arrangement for all your patients. Members who contact St.LukesHealth Customer Service staff will be informed: 1. of the medical providers who have indicated their intention to use the St. Luke s Gap Cover arrangement as a No Gap or Known Gap participating provider and who have requested to be included on the Customer Service Listing. 2. that there will be no patient contribution for members who use a No Gap Participating Provider. 3. that there will be a maximum patient contribution per service provided to members who use a Known Gap participating provider and that the medical provider should obtain informed financial consent from the member prior to treatment or in the case of an emergency, as soon after treatment as practical. St.LukesHealth Customer Service staff will not make recommendations to members regarding their choice of Medical Practitioner. ENQUIRY SUPPORT For all enquiries please call When making an enquiry please request one of the following services: Member eligibility check: We will require you to identify your practice and we will also request the patient s name and date of birth. Claim enquiry: We will require you to identify your practice and we will also request the patient s name and date of birth. Details of the patient account may also be requested. St. Luke s Gap Cover arrangement enquiry: You will be transferred to the appropriate person dependent on the nature of your enquiry. STATIONERY SUPPLIES Samples of the forms required under the St. Luke s Gap Cover arrangement are included in the Appendices. Supplies of the following can be obtained from St.LukesHealth. Batch Summary forms Stationery Order forms Estimate of Medical Fees pro forma Envelopes St. Luke s Gap Cover Brochures St.LukesHealth Product Brochures St. Luke s Gap Cover Posters Simply complete the stationery order form (a copy is included in the Appendices) and forward it to St.LukesHealth in one of the following ways: Fax: (03) Post: PO Box 915, Launceston, TAS, or Send your order by @stlukes.com.au How can I be included on the Customer Service Listing? Simply complete the Request for Customer Service Listing form included in the Appendices and return it to St.LukesHealth. 4 st.lukes GAP cover - information for medical practitioners

7 St. Luke s Gap Cover request form SECTION 1 Provider Details Provider Name Main Practice Address State Postcode Provider Number If you have more than one practice location, please show the additional locations on the reverse side of this form. Medical Specialty(s) SECTION 2 Contact Details Contact Name Postal Address State Postcode Telephone Number Fax Number address Please complete a Stationery Order form to order your required stationery. SECTION 3 Payment Details How do you wish to receive benefit payments? by electronic funds transfer (EFT)*; or by cheque *If you selected EFT, please complete the EFT Payment form. SECTION 4 Customer Service Listing Do you wish to be included on the Customer Service Listing? Yes* No *If Yes, please complete the Request for Customer Service Listing form. Provider Signature Date / / Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03)

8 St. Luke s Gap Cover request form (cont d) Other practice details 2nd Practice Address State Postcode Provider Number 3rd Practice Address State Postcode Provider Number 4th Practice Address State Postcode Provider Number 5th Practice Address State Postcode Provider Number 6th Practice Address State Postcode Provider Number

9 EFT payment form Provider Details for EFT Payment Provider Name Date / / Provider Number Provider ABN Address Postcode New authority Change to existing authority Account Details Please deposit my payments to the following account: Type of account (tick one box) Trading Bank Savings Bank Building Society/Credit Union Name of Financial Institution Address of Branch BSB Number Account Number Name in which account is held Phone No. Signature of account holder Signature of account holder (if joint account) To ensure payment to the correct account, please confirm the BSB details with your Bank/Building Society/Credit Union. Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03)

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11 Request for customer service listing By completing the form below you can request to be included on the Customer Service Listing of No Gap and Known Gap Participating Providers. This listing is available to St.LukesHealth members from any St.LukesHealth office and from our web site at Your name can also be made available to General Practitioners on your request. Inclusion on the Customer Service Listing is entirely optional and has no bearing on your choice to participate in the St. Luke s Gap Cover arrangement. If you do request to be included on the list, you will be indicating to St.LukesHealth members your intention to bill all St.LukesHealth patients under the St. Luke s Gap Cover arrangement. Please see overleaf for conditions of the Customer Service Listing. Yes, please include my name and practice address(es) on the following Customer Service Listings: Customer Service Listing available to members in hard copy, by telephone or on the St.LukesHealth web site Customer Service Listing provided to General Practitioners I wish to be listed as a: No Gap participating provider Known Gap participating provider (Note: You can change your election at any time by notifying St.LukesHealth.) Provider Name Provider Number Medical Specialty(s) Main Practice Address Postcode Telephone Number Fax Number Provider Signature Date / / Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03)

12 Request for customer service listing (cont d) Conditions of the Customer Service Listing: Participating Providers who have elected to make the above information about their practice known to St.LukesHealth members, may withdraw from the customer service listing by giving St.LukesHealth 30 calendar days notice in writing of their decision. St.LukesHealth may withdraw the Participating Provider s name from the customer service listing by giving 30 calendar days notice in writing of its decision. St.LukesHealth may also withdraw the Participating Provider s name from the customer service listing immediately where: a) there is evidence that the Participating Provider has not complied with the St. Luke s Gap Cover operating guidelines and/or billing and claiming guidelines; b) there is evidence that the Participating Provider has not complied with the patient charge conditions; c) the Participating Provider is or becomes unregistered or suspended under the laws of the relevant State or Territory in which case they must notify St.LukesHealth; Members who contact St.LukesHealth Customer Service staff will be informed: 1. of the medical providers who have indicated their intention to use the St. Luke s Gap Cover arrangement as a No Gap or Known Gap participating provider and who have requested to be included on the Customer Service Listing. 2. that there will be no patient contribution for members who use a No Gap Participating Provider. 3. that there will be a maximum patient contribution per service provided to members who use a Known Gap participating provider and that the medical provider should obtain informed financial consent from the member prior to treatment or in the case of an emergency, as soon after the treatment as practical. St.LukesHealth Customer Service staff will not make recommendations to members regarding their choice of Medical Practitioner. d) the Participating Provider no longer carries professional indemnity with a recognised indemnity provider in which case they must notify St.LukesHealth. 10 st.lukes GAP cover - information for medical practitioners

13 Stationery order form Provider details for delivery purposes Provider Name Address Date / / Contact Name Postcode Contact Telephone Number Stationery order ITEM NUMBER REQUIRED Batch Summary Forms Stationery Order Forms Envelopes St. Luke s Gap Cover Brochures St.LukesHealth Product Brochures St. Luke s Gap Cover Posters Estimate of Medical Fees Pro Forma Electronic copy Paper copy If electronic copy requested, please supply address below. Any special delivery instructions Please return this form to St.LukesHealth, PO Box 915, Launceston, Tasmania, 7250 or fax to (03)

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15 Batch summary SECTION 1 Provider Details Provider Name Practice Address Provider Number Contact Name Phone No. Fax No. SECTION 2 Batch Details Lodgment Date / / Batch $ Total Account Ref / Surname SECTION 3 Comments: Declaration: 1. Have the patients included in this batch been provided with an Estimate of Medical Fees and has informed financial consent been obtained? YES NO Not Applicable as No Gap applies. 2. Have you disclosed to all patients any financial interests you have in any product or service recommended or given to the patient? YES NO N/A The Account Reference column must be completed. The other columns need to be completed if the requested information is not shown on the patient account. St.LukesHealth Member Number Medicare Number Medicare Card Ref. Hospital Name SAMPLE ONLY I declare that the services listed on the attached account(s) were provided by me or on my behalf and that the services were rendered to the patient(s) whilst admitted as a private patient of an approved hospital or day hospital facility. This medical practice agrees to bill St.LukesHealth directly for the services listed on the attached account(s) and for these accounts accepts the operating, billing and claiming guidelines of the St. Luke s Gap Cover scheme as advised by St.LukesHealth. Signature of authorised person Name of authorised person

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17 SAMPLE ONLY

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20 abn w stlukes.com.au e @stlukes.com.au Head Office 17 The Quadrant Mall Launceston 7250 t f Branch Offices 50a Murray Street Hobart 7000 t f Rooke Street Devonport 7310 t f Cattley Street Burnie 7320 t f Smith Street Smithton 7330 t f Orr Street Queenstown 7467 t f Emu Bay Road Deloraine 7304 t f A Registered Health Benefits Organisation 5133