Health Fund invoices: No Gap, Known Gap, or Private?

Known Gap and No Gap invoices rely on your (or your doctor's) health fund agreement with the fund you are billing.
When billing under a health fund agreement, a provider must use the private health fund's fee schedule.
If you choose to send an electronic Known Gap or No Gap claim to a health fund with which you do not have an agreement, it is our understanding that you may receive a reduced rebate amount in your payment from the fund. We recommend that you confirm with the fund what fees you are entitled to charge.

The main difference between Health Fund: Known Gap/No Gap invoices and Health Fund: Private invoices is who is responsible for paying for the service provided.

Known Gap/No Gap invoices are paid to you by the health fund.
- For Known Gap claims, the patient is also responsible for paying an out-of-pocket gap fee.
Private invoices are paid to you by the patient.
- It is then the patient's responsibility to claim their rebate back from the fund.

We are often asked, "Can I create a Health Fund: Private invoice for a patient with private health insurance?"

You definitely can create a Health Fund: Private type invoice for patients who are insured by a health fund. It simply means that you will be billing the patient directly for the service, instead of billing their health fund. The patient is then responsible for seeking their own rebate from Medicare and their private health fund.

More detail on each billing type can be found below.

Known Gap

Known gap claims:

Are billed directly to the health fund (the health fund is responsible for paying the invoice).
Include a gap fee (out-of-pocket cost) which is payable to your practice by the patient.
Use the health fund's own fee schedule to determine item fees.
Are paid according to the fund's scheduled rebate amount.
Can be sent online via ECLIPSE to participating Australian health funds.
The gap fee can be per invoice, or per item (for AHSA health funds - see below).

Known Gap AHSA funds

Health funds under the Australian Health Services Alliance (AHSA) umbrella set their fees differently to other funds.

Depending on your health fund agreement, AHSA funds may calculate the gap fee (out-of-pocket cost) per item, rather than per invoice.

The per item gap is determined by a calculation based on the AMA fees. Therefore, it is only possible to charge patients an AHSA gap if you are a member of the AMA.

AHSA per-item gap

You will notice that when billing an AHSA fund, Gentu has an Apply AHSA Gap button:

After adding all your items, you can click this button to apply the AHSA per-item gap.

When determining an AHSA per-item gap fee, Gentu will always calculate two potential gap amounts, and apply whichever is the lesser amount.

When you press Apply AHSA Gap:

Gentu will calculate the item's AMA schedule fee minus the fund's rebate amount.
It will then compare this calculated amount to the fund's maximum per-item gap fee.
Whichever is the lesser fee amount will be selected as the gap fee for that item.
Gentu will complete the above calculation for each item on the invoice.
If there are MPR-applicable items on the invoice, then Gentu will compare the (AMA fee - fund rebate) amount to the maximum known gap fee after applying the MPR scale to the gap.

In the example below, the AHSA gap has been applied.

You can see that the gap fee for item 105 is equal to the (AMA fee - fund rebate) amount.

This is because the (AMA fee - fund rebate) amount for item 105 is less than the maximum per-item gap fee of $400.

In the next example, below, you can see the gap fee for the second item is $200. This is because the MPR has been applied to the maximum per-item gap fee.

For more information, please refer to the AHSA's Billing & Business Guidelines document.

For a list of funds under AHSA, please see this section of the AHSA website.

No Gap

No Gap claims:

Are billed directly to the health fund (the health fund is responsible for paying the invoice).
Use the health fund's set schedule of rebates to determine how much you will be paid.
Can be sent online via ECLIPSE to participating health funds.
Do not include a gap fee (out-of-pocket cost) to the patient.

Private

Health Fund: Private invoices differ from No Gap and Known Gap claims, in that:

The patient is responsible for paying the entire invoice.
The patient is then responsible for claiming their own rebate back from Medicare and/or their private fund.
You can can use your own private billing schedule to set the item fees.
Health Fund: Private invoices can be transmitted electronically through ECLIPSE.

Insured vs. Uninsured

When you create an invoice, Gentu defaults to the Self invoice type.

If you select the Inpatient billing option, Gentu will ask you if the patient is Insured or Uninsured.

Selecting Insured will change the invoice to the Health Fund: Private invoice type.
Selecting Uninsured will retain the Self: Inpatient invoice type.

While both types are used to bill inpatient services, the difference between these two invoice types is the rebate that the patient receives.

Insured patients (Health Fund: Private) are generally entitled to the 100% MBS rebate under their health fund and Medicare.
Uninsured patients (Self: Inpatient) are only entitled to the 75% MBS rebate from Medicare.

Therefore if the patient does have a private health fund, but you still wish to bill them privately; billing them under the Health Fund: Private invoice type will ensure they receive a higher rebate amount.

FAQ

> Can I charge the patient a booking fee alongside a No Gap claim?

It is not possible to include any kind of out-of-pocket cost to the patient on a No Gap claim. No Gap claims do not allow you to set a gap fee.

It is our understanding that the Royal Australasian College of Surgeons (RACS) strongly discourages the practice of including out-of-pocket costs to patients while still claiming a No Gap rebate under your health fund agreement.

If you wish to charge the patient a higher fee than the rebate amount listed on the health fund's fee schedule, you may wish to consider creating a Health Fund: Private invoice instead, or a Known Gap invoice (depending on your agreement with the health fund in question).

If you are unsure, we recommend that you speak to the health fund to enquire about the fees you are entitled to charge patients.

> Can I set my own gap fee on a Known Gap invoice?

It is technically possible to manually edit an invoice item's fee to increase the gap fee.

However, when billing a Known Gap invoice under your health fund agreement, it is our understanding that the claim may be rejected or significantly underpaid if you set a higher gap fee than what you are entitled to bill under your agreement.

> I am not sure what my maximum known gap is.

If you are not sure of the maximum known gap that you're entitled to charge; please refer to any documentation from the health fund.

Alternatively, please contact the health fund directly to enquire.

> Why can't I claim a Health Fund: Private type invoice via ECLIPSE?

You cannot submit a Health Fund: Private type invoice through ECLIPSE because the health fund is not responsible for paying the invoice. You cannot claim the cost of the service back from the health fund because it the patient who is responsible for paying the invoice. Instead, you should print the invoice and give it to the patient.

> Can I create a Health Fund: Private invoice for outpatient services?

The Health Fund account type is only able to be used for inpatient billing.

It is not possible to create a Health Fund: Private invoice for outpatient services.

> Can I charge a patient private fees even if they are insured by a health fund?

Absolutely. You can do this by creating a Health Fund: Private invoice. Please see the relevant section above for more information.

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