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If you work in a practice that regularly generates gap quotes for patient procedures, there's a good chance the majority of these will be for AHSA health funds. It can often be unclear how much you can charge as a gap for these procedures, so this article is designed to assist you in determining the correct gap amount you can charge for the procedure being performed.
From 1 July 2020, AHSA have changed how your patients' out of pocket costs can be billed. Please read the below article to ensure you have configured your AHSA funds correctly.
It's a good idea to understand which agreement you (or your doctors) have with AHSA and if you are part of Access Gap Cover (AGC) before generating any quotes. You should also ensure you are familiar with which health funds are Participating AHSA members.
For Gentu to automatically calculate the Max Known Gap for a fund, you will need to configure the gap against each fund and provider.
- Navigate to Settings > Health Funds
- Select the health fund you wish to update
- Under Practitioner Details, select a provider
- Enter the Max Known Gap that is to be charged
- Select Save to close the window
You can repeat this process for each provider, then select Save or Cancel to go back to the list of Health Funds. You can then move to the next fund to repeat this process until all funds have the correct gap entered.
After setting up your AHSA funds to correspond with the new maximum known gap, you will be ready to invoice.
When you create a Known Gap, you may note that the Apply AHSA Gap button is no longer visible. Instead, the Known Gap should list $500, and you can select Apply This Gap to add the $500 to the invoice.
If you haven't been able to set the new known gap, you can also manually enter $500 into the Known Gap field at the time of invoicing.
From 1 July 2020, AHSA have changed their rules respective to billing under AGC. From this date, each provider will be able to charge the patient an out-of-pocket gap of up to $500 per episode.*
Obstetricians may charge a co-payment up to $800 per confinement for items related to Management of Labour and Delivery as defined in the Medicare Benefits Schedule (MBS).
*AHSA's definition of per episode: "The period of admitted patient care between a formal or statistical admission and a formal or statistical separation, characterised by only one care type."
Example - If a patient changes care type (in the same or different hospital), e.g. Acute to Rehabilitation, then back to Acute would be three separate episodes. This would apply even if there has not been more than a 7-day break between two acute episodes as there was a separation between each care type.
For further information pertaining to these changes, please see AHSA's 1 July Changes or contact AHSA directly using the below details.
|AGC Freecall||1800 664 277|
|Phone||03 9813 4088|
|Fax||1800 670 898|
If you find that you need to raise an ECLIPSE claim for an AHSA fund, where the service date was prior to 1 July 2020, the old AGC rules will apply. In this case, you can set the Service Date on the invoice as any date prior to 01/07/2020 and the Apply AHSA Gap button will be present to apply a gap per the previous AGC rules.
When applying a maximum known gap per item, the amount charged per item is based on the AMA fee.
If the AMA fee minus the health fund rebate is less than the maximum known gap of the health fund, then the gap per item should be the AMA fee minus the Health Fund Rebate. This calculation is done per each item on the quote, it is not an overall calculation.
If the AMA fee minus the health fund rebate is greater than the AHSA maximum known gap ($400) then the maximum known gap of $400 is used.
For multiple procedures, the allowable gap will reduce by 50% on the second procedure and 25% for procedures thereafter.
Obstetricians may charge a co-payment up to $800 per confinement for items that relate to Management of Labour and Delivery as defined in the Medicare Benefits Schedule (MBS).
Below are some examples of how patient gap amounts are calculated prior to the new AGC rules as of 1 July 2020.
|AHSA Maximum Gap per item = $400||AMA Fee||Health Fund Rebate||Patient Gap||Notes|
|MBS Item A||$700||$600||$100||AMA fee - HF rebate < max known gap, therefore the $100 gap amount is used|
|MBS Item B||$1500||$800||$400||AMA fee - HF rebate > max known gap, therefore max gap of $400 is used|
|MBS Item C||N/A||$900||$400||AMA fee not available, therefore max gap of $400 is used|
|MBS Item D||$300||$300||$0||AMA fee - HF rebate < max known gap, therefore no gap ($0) is used|