South East Regional Hospital probed over public patient billed referrals claim

Bega hospital GP referrals under investigation

Concerns relating to GP referrals for specialist consultations at Bega's South East Regional Hospital (SERH) have been forwarded to the federal Health Department, which is now seeking further information.

The matter was raised with Health Minister Greg Hunt's office, by Merimbula GP Frank Simonson, after he was asked to provide named referrals for patients attending SERH even though they were public patients.

Dr Simonson said the only reason for a named referral was to apply to the Medicare Benefits Scheme for payment - but specialists are already paid by the federal government.

"If you are referring a patient to a specialist and they are a private patient, you refer to a named specialist. However if they are not a private patient you refer the patient to the specialist outpatients department. It is then up to the department to even out the workload between the specialists employed," Dr Simonson said.

The National Health Reform Agreement (or NHRA), specifically clause G17, outlines that services provided to public patients should not generate charges against the commonwealth Medicare Benefits Scheme.

Dr Simonson said if there were applications to the scheme it could mean the federal government was paying twice for the same service.

ACM would like to make it clear that there is no suggestion of fraudulent action by any specialists at the hospital.

'Named referrals requested'

Dr Simonson said that after writing a referral on several occasions for the specialist outpatients department, he was then told a named referral was needed.

"The patients are cranky and I'm put in a difficult position," he said.

He said he was recently asked by SERH staff for a referral in the names of two specialists.

"I phoned SERH and asked why, and was told both names were needed for billing," Dr Simonson said.

His concern reached the point where he decided to write to the Health Minister, Greg Hunt.

Health Department 'concerned'

In a response from Mr Hunt's office, a department official expressed concern over "the description of South East Regional Hospital in requesting named referrals from GPs".

"Under the National Health Reform Agreement (NHRA), an eligible patient presenting at a public hospital outpatient department will be treated free of charge as a public patient unless the patient has been referred to a named medical specialist who is exercising a right of private practice and the patient chooses to be treated as a private patient," the official wrote.

"If named referrals are sought as a default requirement for access to an outpatient clinic, there is a possibility that the Medicare Benefits Scheme could be billed for public patients. This would result in a duplicate Medicare payment and in such circumstances, repayments may be sought," the Health Department official said.

The department said it was able to investigate circumstances where hospitals are not operating in accordance with the NHRA and has asked Dr Simonson to contact the director of Hospital Systems Section to discuss the matter further.

A public patient in a public hospital should be provided treatment, throughout the hospital episode, free of charge, providing the patient has a current Medicare card and the treatment is deemed clinically necessary.

The Department of Health

The Department of Health website outlines the the protocol for public patients in a public hospital:

"A public patient in a public hospital should be provided treatment, throughout the hospital episode, free of charge, providing the patient has a current Medicare card and the treatment is deemed clinically necessary.

"If a patient is treated as a public patient this means that no claims should be made against the Medicare Benefits Schedule, regardless of whether that service is bulk billed or not (a bulk billed service is, by definition, not a public service).

"Importantly, all associated care for public patients is the responsibility of the hospital, including all pathology and diagnostic tests."

'Referral pathways must not be controlled'

In response to questions from ACM, a Department of Health spokesman said the department encouraged anyone concerned about medical billing or related practice to report the details to the department so that it could be fully investigated.

He said that under the Business Rules of the NHRA "referral pathways must not be controlled so as to deny access to free public hospital services or so that referral to a named specialist is a prerequisite for access to outpatient services".

The department takes allegations of MBS non-compliance very seriously and concerns are reviewed in accordance with the department's compliance assessment procedures."

Department of Health spokesman

"A public patient should not be directed by hospital staff to receive outpatient services as a private patient, nor should the patient's GP be asked by hospital staff to retrospectively provide a referral to a named specialist to facilitate the billing of services to the MBS," the Department of Health spokesman explained.

He said "the department takes allegations of MBS non-compliance very seriously and concerns are reviewed in accordance with the department's compliance assessment procedures".

"Any action the department may take is subject to privacy and secrecy provisions set out in legislation. This means that even where the department is actively pursuing a matter, it is prevented from providing details," the spokesman said.

The Southern NSW Local Health District has also been asked for a comment.

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