IMPACT OF MEDICARE

1
IMPACT OF MEDICARE
ABN 23 000 543 788
College of Educational Developmental
Psychologists (NSW) Professional Development
Seminar Series 2007 supported by Sydney
Childrens Hospital, Psychology Department

• PROFESSIONAL AND ETHICAL PRACTICE ISSUES

2
IMPACT OF MEDICARE

• Neil Nicoll and Lizette Campbell will outline
  practical information about Medicare and provide
  case based examples of paperwork associated with
  the Medicare scheme. A range of mental health
  care plans, referral letters, invoices and
  feedback letters will be used to highlight common
  problems and provide exemplars.

3
IMPACT OF MEDICARE

• At the conclusion of the presentation, discussion
  will be invited on issues of particular concern
  to Psychologists working with children and
  families in educational and developmental
  settings.
• The NSW Branch of the College of Educational and
  Developmental Psychologists is keen to ensure
  that this information is made available for
  inclusion in the review process that will take
  place at the end of the first year of the scheme.

4
Better Access to Mental Health Care

• Better Access to Mental Health Care initiative
  introduced new mental health Medicare items on
  1st November 2006.
• Enables people with diagnosed mental disorders to
  access services from psychologists

5
PSYCHOLOGISTS AND CLINICAL PSYCHOLOGISTS

• Two sets of Medicare items one for registered
  psychologists and the other for clinical
  psychologists.
• Clinical psychology items can only be provided by
  approved clinical psychology practitioners. 
• Mental health psychology Medicare items involve
  two categories
• 'general' psychology services
• 'specialist' clinical psychology services

6
WHAT IS A MENTAL HEALTH DISORDER?

• Psychotic disorders
• Schizophrenia
• Bipolar disorder
• Phobic disorders
• Anxiety disorder
• Adjustment disorder
• Depression
• Sexual disorders
• Conduct disorder
• Bereavement disorders

• Post-traumatic stress disorder
• Eating disorders
• Panic disorder
• Alcohol use disorders
• Drug use disorders
• Sleep problems
• Attention deficit disorder
• Obsessive Compulsive Disorder
• Co-occurring anxiety and depression

7
WHAT YOU CAN OFFER

• Eligible patients can generally receive
• Up to 12 individual services in a calendar year.
  Referring doctor will assess client progress
  after the first six sessions.
• Up to 12 group therapy services in a calendar
  year where seen as appropriate by referring
  doctor and the psychologist.

8
PRIVATE HEALTH VS MEDICARE

• Clients cannot use private health insurance
  ancillary cover to top up the Medicare rebates
  for these services.
• i.e., cannot cover the gap
• HCF GP or Psychologist can complete a psychology
  benefit authorisation form for Multicover
  patients who have exhausted their Medicare
  psychology benefits. Psychology service must be
  necessary and ongoing and with state registered
  psychologist.

9
GENERAL PSYCHOLOGY SERVICES

• Focused Psychological Strategies - psychologists
  items 80100 to 80120
• Chronic psychotic disorders
• Acute psychotic disorders
• Schizophrenia
• Bipolar disorder
• Phobic disorder
• Generalised anxiety disorder
• Adjustment disorder
• Unexplained somatic complaints
• Depression
• Sexual disorders
• Conduct disorder
• Bereavement disorder

• Post-traumatic stress disorder

• Eating disorders
• Panic disorder
• Alcohol use disorders
• Drug use disorders
• Mixed anxiety and depression
• Dissociative (conversion) disorder
• Neurasthenia
• Sleep problems
• Hyperkinetic (attention deficit) disorder
• Enuresis (non-organic)
• Obsessive Compulsive Disorder
• Mental disorder, not otherwise specified

10
GENERAL PSYCHOLOGY SERVICES (CONTINUED)

• Provision of approved Focused Psychological
  Strategies (FPS)
• Psycho-education (including motivational
  interviewing)
• Cognitive behaviour therapy, including
• Behavioural interventions - behaviour
  modification exposure techniques activity
  scheduling
• Cognitive interventions - cognitive therapy
• Relaxation strategies - progressive muscle
  relaxation controlled breathing
• Skills training - problem solving skills and
  training anger management social skills
  training communication training stress
  management parent management training
• Interpersonal therapy (especially for depression)
  

11
Reporting requirements

• On completion of the first six services, the
  psychologist must provide a written report to the
  referring medical practitioner, including
  information on
• assessments carried out on the client
• treatment provided, and
• recommendations on future management of the
  client's disorder
• A written report must also be provided to the
  referring medical practitioner at the completion
  of the second set of six services provided to the
  client.

12
SPECIALIST CLINICAL PSYCHOLOGY SERVICES

• Psychological therapy - clinical psychologist
  items 80000 to 80020
• Chronic psychotic disorders
• Acute psychotic disorders
• Schizophrenia
• Bipolar disorder
• Phobic disorder
• Generalised anxiety disorder
• Adjustment disorder
• Unexplained somatic complaints
• Depression
• Sexual disorders
• Conduct disorder
• Bereavement disorder

• Post-traumatic stress disorder
• Eating disorders
• Panic disorder
• Alcohol use disorders
• Drug use disorders
• Mixed anxiety and depression
• Dissociative (conversion) disorder
• Neurasthenia
• Sleep problems
• Hyperkinetic (attention deficit) disorder
• Enuresis (non-organic)
• Obsessive Compulsive Disorder
• Mental disorder, not otherwise specified

13
BILLING OPTIONS

• PRIVATE BILLING
• When a client is billed they can either
• pay the full amount of the consultation and use
  their detailed receipt to claim a Medicare
  rebate or
• pay the difference between the Medicare rebate
  and the total account amount, and then claim the
  rebate from Medicare to forward to the
  psychologist later or
• claim from Medicare using their unpaid account.

14
BILLING OPTIONS CONTINUED

• Bulk billing
• When bulk billing is used, the psychologist
  receives direct payment from Medicare by
  completing direct billing forms for every service
  provided to the client. These direct billing
  forms consist of
• a claim form (Non-hospital patients allied health
  professional - DB1N-AH)
• assignment of benefits form (Bulk bill voucher
  (Allied Health Professional) - DB2-AH).

15
QUESTION 1 Best practice psychological
assessment of a child involves detailed
interviewing of the childs parents, which is
usually most appropriately undertaken without the
child present. Would this be considered a valid
service under the clinical psychology Medicare
items?
16
ANSWER 1

• A valid Medicare service requires the identified
  patient to be present, so a session cannot be
  conducted with the childs parents alone under
  the Better Access Medicare initiative. The
  discrepancy between best practice psychological
  assessment of a child and allowable services
  under Medicare has been raised with the
  Department of Health and Ageing and will be
  considered in the post-implementation review of
  the initiative.

17
QUESTION 2For the clinical psychology Medicare
items, what types of assessment are allowable
under provision of psychological assessment?

• ANSWER 2 The term psychological assessment
  refers to clinical interviewing for the purposes
  of making a mental health diagnosis. Other forms
  of assessment, such as neuropsychological
  assessment and intelligence testing, are not
  valid services under the Better Access Medicare
  initiative.

18
QUESTION 3 How detailed do reports to the
referring medical practitioner have to be?

• ANSWER 3 The amount of detail in the report to
  the referring medical practitioner is not
  specifically mandated. The Medical Benefits
  Scheme Explanatory Notes do state that the report
  should include information about assessments
  carried out, treatment provided and
  recommendations on the future management of the
  client's disorder. In meeting these requirements,
  the psychologist should use clinical judgement on
  what information is appropriate to include in the
  report.

19
QUESTION 4 Can a provisionally
registered/probationary psychologist provide
psychological services under Medicare?

• ANSWER 4 No, only psychologists who are fully
  registered with the Psychologists Registration
  Board in the State or Territory in which they are
  practising are eligible to provide psychological
  services under Medicare. Students who are under
  the supervision of fully registered psychologists
  are also not eligible to provide psychological
  services under Medicare (unless the student is
  already a fully registered psychologist).

20
QUESTION 5 What is involved in a GP Mental
Health Care Plan?

• ANSWER 5 In order for a GP to refer a client for
  psychological services under the Better Access to
  Mental Health Care initiative, the GP must first
  complete a detailed assessment and diagnosis of
  the client. The GP must then prepare the GP
  Mental Health Care Plan, which includes
  documenting results of the assessment, client's
  needs, goals and actions, referrals and required
  treatment/services, and a review date. There is
  no particular form that is used for preparing the
  Mental Health Care Plan. Clients are encouraged
  to book a longer session with their GP if they
  are requesting a referral for psychological
  services, in order to enable the GP to complete
  the assessment and GP Mental Health Care Plan.

21
QUESTION 6 What are the reporting and medical
practitioner review requirements for provision of
the second set of six psychological services?
22
ANSWER 6

• Psychologists must provide a written report
  to the referring medical practitioner following
  the first six psychological services or on
  completion of that course of treatment (which
  will be a maximum of six services, but could
  cover less than six services depending on the
  nature of the referral). The written report
  should include information on
• any assessments carried out
• any treatment provided
• recommendations on future management.
• The client should be reviewed by the referring
  medical practitioner after the first six
  psychological services and following receipt of
  the psychologists report. The review will
  determine whether the second set of six
  psychological services is required. In some
  instances, a referring medical practitioner may
  authorise the second set of six psychological
  services without reviewing the client in person.
  Where this occurs, the psychologist should
  document any telephone conversation with the
  referring doctor and seek written authorisation
  from him/her to ensure that the validity of the
  second set of six psychological services can be
  substantiated at a later date, if required.

23
QUESTION 7Which psychological services are
counted in the maximum number of services a
client can receive?
24
ANSWER 7

• Clients can receive up to 12 individual
  psychological services in a calendar year.
• The maximum of 12 allowable services includes any
  other psychological services provided either by
  other psychologists or by other eligible social
  workers or occupational therapists, or by GPs.
• Services received under Better Outcomes - Access
  to Psychological Services (ATAPS) are also
  included in the 12-service limit for
  psychological items. However, services received
  under the Allied Health and Dental Care
  initiative (formerly 'MedicarePlus') are not
  counted in the 12 allowable services.
• In addition to these 12 individual psychology
  services, clients can also receive up to 12 group
  session psychology services in a calendar year.
  The maximum of 12 group services includes
  clinical psychology items, and FPS items provided
  by psychologists or eligible social workers or
  occupational therapists.

25
QUESTION 8 How much can a psychologist charge
for providing services under Medicare?

• ANSWER 8 Psychologists providing Medicare
  rebateable services may set their own fees but
  the Medicare rebate for each item is a set
  amount. However, if a psychologist chooses to
  direct bill Medicare for a service (i.e. bulk
  bill), the Medicare rebate for that service must
  be accepted as the full fee for that service.

26
QUESTION 9 Does the Medicare Safety Net apply to
client out-of-pocket expenses under this
initiative?

• ANSWER 9 The client is responsible for paying
  any charges in excess of the Medicare benefit for
  items under this initiative. However, these
  out-of-pocket costs will count towards both the
  original and the extended Medicare Safety Nets
  for that client.

27
QUESTION 10 What about clients with private
health insurance cover?

• ANSWER 10 Clients cannot use their private
  health insurance ancillary cover to pay the gap
  between the Medicare rebate and the charge for
  psychological services.

28
QUESTION 11 WILL I BE AUDITED BY MEDICARE
AUSTRALIA? IF SO, WHAT WILL IT INVOLVE?

• ANSWER 11 Psychologists providing services under
  the Medicare Benefits Scheme (MBS) may be subject
  to random compliance audits conducted by
  Medicare Australia.
• The audit involves three checks
• (1) confirming with the referring doctor that the
  client was indeed referred
• (2) checking with the psychologist that the
  service was provided and (3) verifying with the
  client that they actually received the service.
• Approximately 2,000 random compliance audits are
  conducted every year.
• No current research audit. However, for Medicare
  Australia auditing purposes, psychologists are
  required to retain documentation of the medical
  practitioners referral for 24 months from the
  date the first service under that referral was
  provided.  

29
(No Transcript)
30
Practicalities

• Mental health care plans
• Fees and Invoices
• Correspondence
• Your intake system

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
Fee Schedules Invoices

• 2 most common items are
• Clinical Psychologist 50 minutes
• Item 80010
• Schedule fee is 129.40
• Rebate is 110.00
• Psychologist 50 minutes
• Item 80110
• Schedule fee is 88.20
• Rebate is 75.00

38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
Professional Correspondence

• Use your letters to educate the GPs and
  paediatricians who are referring to you.
• Examples of
• Letters to GPs of existing families.
• Initial letters
• 6 session review letters

43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
Reviews and Exceptional Circumstances

• GP 6 sessions 6 sessions
• Item 2712
• Paediatrician may not be planning to see a child
  for 3 to 6 months
• Correspondence and invoices must reflect
  exceptional circumstances

48
(No Transcript)
49
(No Transcript)
50
Complicated Referrals

• Case of T 11 yrs
• Mother sought referral due to my experience with
  children with complicated learning needs
• Prepared to travel long distance
• Initial consult planned with mother only to
  review extensive documentation.
• She arrived at this interview with a GP Medicare
  referral

51
Information taken by secretary over the phone

• Reason for Referral Anxiety problems
• Background to Referral
• Mum says he can memorize a book
• Has had language problem because of hearing
  Hyperopia has been diagnosed.
• Mum had 4 hearing tests before age of 5 CAPD
  diagnosed.
• WISC 3 (Apr 2004) WISC 4 (Sept 2006) Verbal IQ
  depressed but his other scores were all over the
  place.
• It was suggested that T has Hyperlexia Mum says
  he has been misdiagnosed.
• Has seen numerous speech therapists. T refused
  to work with last one and Mum now does speech
  therapy at home

52

• Had been suggested she apply for Funding by
  labelling T Aspergers. Hyperlexia has also been
  suggested. Mum says these labels are wrong and
  she refused to allow this. She decided to begin
  home schooling instead.
• Home schooled for last 2yrs 4 months. She
  mentioned that she has spent up to 10,000 on
  resources to help T. Mum says her intention has
  always been to send T back to School. She would
  like help with strategies to manage the anxiety
  symptoms and has specifically requested you
  because of your association With GLD kids.
• Will travel.

53
(No Transcript)
54
Discussion Questions

• Case of T.
• Despite detailed intake, referral does not really
  match up.
• Should this be a Medicare referral?
• What do you do when you think the referral has
  been either engineered by the parent or perhaps
  not thought through by the GP?

55
(No Transcript)
56
Further questions raised

• How do you manage generalist referrals in a
  specialist practice?
• How do you manage referrals that are outside your
  usual area of expertise, particularly when there
  is a limited intake process?
• Do you limit the number of referrals or the type
  of referrals you accept you accept under
  Medicare?
• How do you structure fees and time?
• How do you handle the question of reduced fees or
  differential billing practices for Medicare?
• How do we factor the APS recommended rate, the
  costs associated with being in practice and the
  Medicare scheduled fee?
• How do we balance the desire to support the
  inclusion of psychologists in Medicare, the
  recognition of serious mental health concerns
  facing our society and the awareness that in some
  families the new Medicare benefits are being seen
  as an entitlement, similar to rebates offered
  by private health funds?