Questions?

• Why should I join the Bupa Australia Medical Gap Scheme


• When can a payment be expected and how can the claim it relates to be determined?


• Why are some items paid and others not?


• Why is it important to supply the Medicare number and fund membership number?


• Why aren’t all providers eligible for ‘Full’ Bupa Australia Medical Gap Scheme benefits?


• Why do some items attract a benefit equal to 100% of the MBS fee?


• How can I recognize if a Bupa Australia Medical Gap Scheme benefit has not been paid for a patient and where do I find an explanation for the non-payment?


• I cannot find the item I require on the schedule of benefits


• What will happen in November each year when the main changes to the Medicare Benefits Schedule occur?


• Who should we contact for further explanation of rejection or error description?


• Why can’t a Known Gap be charged for in hospital obstetric services?


• Why can’t a Known Gap be charged for anaesthetic and assistance at operation services?


• How do anaesthetists source patient information?


• Can the practice account forms be used?


• What is Eclipse?


• Why should I use Eclipse?


• How do I become an Eclipse user?

Why should I join the Bupa Australia Medical Gap Scheme?

The Bupa Australia Medical Gap Scheme will save you time and money. You will receive payments quicker, and receiving them as one payment will reduce the paper work for you, your practice and your patients.

When can a payment be expected and how can the claim it relates to be determined?

For manual claims payment can be expected after 20 working days processing period. EFT payments are paid into accounts every Wednesday. For electronic claims payment can be expected within 14 days.

To identify the claim and the payment it relates to check your Medical Payment Detail Report

(For Eclipse payments refer to your Medical Payment Summary Report.)

This report will list:

• Provider batch reference number (your reference number)
• Bupa Australia batch reference
• The amount charged and benefit paid
• A list of patients and the benefits relating to each patient

A slip will be attached to the report indicating any rejections, which will be followed through.

Why are some items paid and others not?

All claims submitted via the Bupa Australia Medical Gap Scheme are subject to the normal Medicare Australia rulings. If there are restrictions for the medical items, some benefits are not payable.

Why is it important to supply the Medicare number and fund membership number?

The Medicare number is required to identify the patient once the claim details have reached the Health Insurance Commission (HIC) for processing.

The fund membership number is required to confirm policy details and eligibility. The patient is required to supply you with their current Medicare number and fund membership details at the time of consultation.

Why aren’t all providers eligible for the 'Full' Bupa Australia Medical Gap Scheme benefits?

When the Bupa Australia Medical Gap Scheme system was first introduced, it was designed to eliminate our member’s out-of-pocket expenses for in-patient medical services provided by their own Specialists and General Practitioners in private practice. Now that the government and the professional training bodies have decided to promote more specialist training in the private sector, it is important that our members do not foot the bill for this training through their premiums as well as their taxes. Hence, providers in training or not fully qualified will not be eligible for the full Bupa Australia Medical Gap Scheme benefit.

Why do some items attract a benefit equal to 100% of the MBS fee?

When the Bupa Australia Medical Gap Scheme system was introduced 10 years ago it was designed to cover or reduce gaps in the most affordable way. Business decisions were made to pay some items at 100% of the MBS fee while providing doctors with the convenience and cost savings of direct billing.

How can I recognize if a Bupa Australia Medical Gap Scheme benefit has not been paid for a patient and where do I find an explanation for the non-payment?

If there is a rejection by Medicare Australia for any reason, this will show on the Medical Payment Detail Report with an error code and explanation. For Eclipse rejections please refer to Medicare Australia Online Manual. Payment amounts are listed in detail on a payment report, which is sent each time a claim has been finalized.

I cannot find the item I require on the schedule of benefits?

Not all items in the Medicare Benefits Schedule appear in the Bupa Australia Medical Gap Scheme Schedule. Only services provided as inpatient services are eligible for the Medical Gap Scheme benefits.

Pathology and Radiology item numbers are contained in separate Bupa Australia Medical Gap Scheme schedules. As we have contracts for most Radiology and Pathology item numbers, these items are not on the internet. If you require a copy, please send an email to sprovops@hba.com.au and an attached file will be returned to you via email. If you require a hard copy please state that in your email.

What will happen in November each year when the main changes to the Medicare Benefits Schedule occur?

Indexation of the Bupa Australia Medical Gap Scheme fees and benefits are revised in line with the Medicare Australia MBS reviews in November each year. This process occurs automatically on 1 November each year unless otherwise advised and shall be determined by taking into account the following things:

• The movement in labour price applicable in the specified State and as published by the Australian Bureau of Statistics;
• The index of movements in Consumer Prices (all groups) applicable in the specified State and as published by the ABS;
• The index of recognised movements in Medical Indemnity rates applicable to the specified discipline.

Who should we contact for further explanation of rejection or error description?

For further clarification of a Bupa Australia Medical Gap Scheme rejection, please call Bupa Australia Medical Gap Scheme in your state.

Why can’t a Known Gap be charged for in hospital obstetric services?

Bupa Australia Medical Gap Scheme does not allow a Gap to be charged for the admitted delivery and confinement as its original benefit amount was calculated to cover both the antenatal services as well as delivery within a global delivery fee. Since the de-evolvement of antenatal fees from the global delivery fee, obstetricians now charge additional fees in the antenatal period.

NASOG strongly prefers a “known gap” arrangement for confinement to “No Gap”.

However, Bupa Australia and NASOG are both concerned that some obstetricians feel the use of Bupa Australia Medical Gap Scheme for the delivery precludes Safety Net rebating of gaps charged under Medical Benefits Schedule (MBS) item 16590 in the antenatal period. This is a consequence of some doctors’ interpretation of the “1/3: 2/3” rule. Some of our privately insured members have been disadvantaged as a result.

Practitioners are assured that for the purposes of the Safety Net rebate, the patient in-hospital “gap” is the difference between the MBS 75% rebate for delivery and the Bupa Australia Medical Gap Scheme benefit. An obstetrician using the Bupa Australia Medical Gap Scheme for a delivery is deemed to be charging this fee even if the patient pays no gap. They may legitimately use MBS item 16590 in the antenatal period with an associated and commensurate gap.

The senior officers of the Commonwealth Department of Health and Ageing with whom we raised this matter had no objection to this interpretation.

They advised that obstetricians can charge 2/3 of the overall fee for services provided in the rooms and 1/3 for the in-hospital services. For the Bupa Australia Medical Gap Scheme, the doctor should charge the same as the Bupa Australia Medical Gap Scheme benefit for the in-patient service. In other words there should be no gap. The doctor can charge the patient whatever he deems reasonable (up to twice the fee for the in-patient service if wishing to remain within the government guidelines), for any non-admitted obstetric services. However the patient may be eligible for the Safety Net rebates to minimise any ‘out-of-pocket’ expenses incurred for in-the-rooms services if the charge is greater than the Medicare rebate.

We hope this information clarifies the legitimate use of Safety Net rebates when using the Bupa Australia Medical Gap Scheme for delivery and confinement and avoids further patients being unintentionally disadvantaged.

Please do not hesitate to telephone Dr Boffa on 1800 060 237 to discuss any aspect of this matter.

Why can’t a Known Gap be charged for anaesthetic and assistance at operation services?

The Bupa Australia Medical Gap Scheme does not allow a Gap to be charged for these services because of the lack of opportunity for meaningful informed financial consent. Only the ‘Doctor of First Referral’ may charge a Known Gap and only under the Bupa Australia Medical Gap Scheme Known Gap Terms and Conditions.

How do anaesthetists source patient information?

To complete accounts anaesthetists can obtain patient details from the doctor of first referral or hospital. We have taken steps to ensure that hospitals have all the necessary information required on the ‘Bradmar’ labels for anaesthetists to complete their accounts.

Can the practice account forms be used?

Yes. It is important to note, however, that a Batch Header Form must be attached and your practice ID number must be written on the batch header.

If you are unsure of the practice ID, please contact Provider Operations on 1800 060 239.

What is Eclipse?

Eclipse is a secure information processing system that uses the internet to link Medicare Australia, health funds and doctors.

Medicare Australia developed Eclipse to enable doctors to lodge, within six months of providing the service, their Bupa Australia Medical Gap Scheme electronically directly to Medicare Australia which then relays their assessment speedily to us for our further assessment and payment. This will help eliminate errors in transmissions between the Medicare Australia and us, thus saving doctors’ time and money. Your software vendor will help you make immediate use of this exciting new development in the Bupa Australia Medical Gap Scheme.

Your software supplier will give you all the information you need but Medicare Australia can also advise you. Either telephone Medicare Australia on 1800 700 199 or access their website on www.medicareaustralia.gov.au.

Why should I use Eclipse?

Eclipse will save you time and money by:

• Improving financial management through faster resolution of claims and quicker payment times
• Improved data integrity, less manual intervention and improved claiming automation
• Online patient verification of Medicare enrolment and health fund membership
• Single point of contact.
• Lower incidence of errors and review time, speedier resolutions, and rejections known immediately
• One system for all health funds
• Claims batching no longer required
• No transaction costs to use the hub for at least 4 years

How do I become an Eclipse user?

If you are not yet registered to use Eclipse or want to know more about electronic claiming go to the Medicare Australia website at www.medicareaustralia.gov.au/providers/online_initiatives/online.htm or call the ebusiness centre on 1300 700 199.