What does NIB's new terms of agreement mean for my patients and myself?

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asked Sep 30, 2015 by admin (1,520 points)
edited Sep 30, 2015 by admin

1 Answer

0 votes
answered Sep 30, 2015 by admin (1,520 points)
edited Sep 30, 2015 by admin
NIB recently introduced new terms of agreement for anaesthetists http://www.nib.com.au/providers/medigap/schedule-of-benefits.  The result of this new agreement is that any anaesthetist "Medigapping" any patient automatically agrees to the new terms of agreements which introduces, amongst other things, practice audit requirements.

Medigapping is their "No gap" agreement in which the anaesthetist sends the invoice to NIB and the fund pays the difference between medicare rate ($14.85) and NIB's unit rate which is $31.50 as of Sept 2015

If yiu choose to avoid agreeing to these terms of agreement the invoice should be sent to the patient and the patient claims their rebate from NIB and Medicare.  NIB in this scenario pay 25% of the Medicare Benefit Schedule (MBS) which is $4.95 per unit and medicare covers 75% ($14.85)

As per the ASA's advice

The sending of a 'Medigap' account implies automatic agreement to these terms and conditions. Importantly, agreeing to 'Medigap' means that no out-of-pocket expense can be charged to the patient. Unlike other insurers, there is no 'known gap' system. However, anaesthetists are free to send patients a private account if they do not wish to utilise the Medigap system. In this case, the patient will receive a total rebate of only 100% of the MBS Fee ($19.80 per unit, as opposed to $31.50 per unit under the Medigap system). Best possible informed financial consent practices are advised in this situation.

NIB has assured the ASA that any anaesthetist working in the private sector, and charging patients on a fee-for-service basis, is eligible to utilise the Medigap product, regardless of their commitment to salaried practice at other times. It is only while actually working for a public hospital, and treating NIB customers admitted as private patients, that the Medigap product does not apply. To this end, the wording under “Practitioner Eligibility for Medigap” (p6 of the new terms and conditions) has been altered. Also, 'private practice', which was previously defined by NIB as involving sole practitioners or groups who receive their 'entire income' from fees charged to patients, has been removed from the “Glossary of Important Terms” starting on p20.

NIB still retains the right to audit doctors’ billing under the Medigap scheme. However, there will now be five business days’ notice given, rather than two. Also, the wording regarding costs of audits has been altered to the effect that “NIB and the practitioner will meet their own costs”. There is no requirement for the anaesthetist to seek patient consent to release information in the case of an audit. The ASA continues to receive queries from members on the issue of audits, and members are again reminded that doctors are not compelled to utilise the Medigap product if they do not agree with the rules regarding audits.

NIB will also publicise individual doctors’ “Medigap participation rate” on its website. It will be stated that this does not guarantee that any individual patient will be covered by Medigap. Doctors’ practice addresses will also be made available to patients, but as stated on p12 of the terms and conditions, “if you do not have consulting rooms, NIB will only publish your name, specialty, and details of your participation in the Medigap scheme”.
Welcome to Patientloops FAQ. This resource is developed to:

A. Help anaesthetists find their way in the complex billing environment of the Medicare Benefits Schedule and Health Funds.

B. Help with questions about Patientloops , the next generation patient management system for anaesthetists.