For practices in Western Australia, HBF uses their own fee schedules and will not follow the AHSA fee schedule like the rest of Australia. As a result, there are a number of considerations that need to be taken into account when you are billing for HBF through Genie that are specific to WA.
Before you begin
It's a good idea to understand the agreement your providers have with HBF prior to starting any billing, as this will allow you to follow the appropriate steps for your specific practice.
It's also important to note that the usual Known Gap method for quoting in Genie will not work for Opt-In/Opt-Out HBF providers in WA. Previously the "Known Gap" amount was 10% above the standard HBF fees. This is no longer the case and the "Known Gap" fees are now the "HBF Fully Covered" Schedule, there is no set amount or percentage - it varies per item.
As the Known Gap & No Gap amounts were previously HBF + 10% most practices will still have the fund & fee schedule named as such but apply the HBF Fully Covered fees.
The HBF Known Gap is not a set dollar amount so a maximum Known Gap amount can't be set against the fund as it's different for every item number.
The type of agreement you have with HBF will allow you to use either the HBF or HBF Fully Covered schedule. The options are as follows:
Full Cover:
Your fees will be fully covered for all in-hospital services provided to all HBF members if you choose to always charge fees up to HBF Fully Covered rates.
Opt In/Opt Out Known Gap Cover:
HBF will pay a benefit equal to the HBF Schedule on those occasions that you charge fees up to HBF Fully Covered rates. With this option your patient pays the difference between the HBF Schedule and your fees.
Please note: This information comes from HBF's Gap Provider Guide. You should confirm directly with HBF before using either of these fee schedules.
Some practices will have an Opt-In/ Opt-Out arrangement, where you can choose to either use the No Gap (HBF Fully Covered), Scheme (manually add the gap when invoicing), or Patient Claim (charge your own private fee). In this case, if you add a gap which makes the fee higher than the HBF Fully Covered amount, you will only get the schedule fee back.
For most practices, you will just have one health fund called HBF. In this case, you would download the HBF Fully Covered fees from Special > Software Updates > Fee Schedules and apply it to this fund. You can then create an Agreement (AG) ECLIPSE claim and use this HBF Fully Covered fee, meaning the patient would have no out of pocket amount.
To workaround these differences, there are few steps you can follow within Genie to allow you to claim using the correct fees.
Health Funds
- Navigate to Open > Billing Items > Health Funds, and ensure you have both HBF and HBF Fully Covered entered as separate health funds. If you only have one or the other, you can add a new fund by clicking the Add button.
- Once you have both funds added, double click on both and Alt-right click into the Brand ID box in the ECLIPSE Capabilities section, then select the code HBF from the list for both funds.
Fee Schedules/Fee types
- Once this is done, navigate to Special > Software Updates > Fee Schedules to download and apply the two fee schedules (HBF and HBF Fully Covered) to each corresponding fund.
- Navigate to Billing > Edit Account Types and click Add to set up a new fee type called HBF Known Gap.
- Locate all the procedure items that get used in your practice. The best way to do this is to use The Item Report.
- Double click on an item from the list and choose to add the HBF Known Gap fee from the Add a Fee drop down menu on the right of the window (above the list of fees).
- Manually copy and paste the HBF Fully Covered fee (on the left) into the HBF Known Gap fee (on the right)
When you are creating a quote for HBF patients for their procedure, you can follow the steps below:
- Before starting your quote, ensure you have HBF set as the patient's health fund in their demographics window
- In the Quotes window, select HBF Known Gap as the fee schedule
- Select Use Known Gap > Use Selected Schedule above
- Add the correct items and click the Calculate Fees button as normal
When billing through ECLIPSE, there are two options you can choose:
Option 1
- Change the patient's health fund to HBF Fully Covered in their demographics window
- Navigate to Billing > IMC Invoice Wizard
- Select the claim type as Agreement (AG)
- The correct fee will be applied when adding the items numbers and will come back as an underpayment from the fund when processed
- Receipt the part-paid amount from the fund & re-assign the invoice to the patient so they can pay the gap amount
Option 2
- Leave the patient's health fund as HBF
- Navigate to Billing > IMC Invoice Wizard
- Select the claim type as Scheme (SC)
- When adding the items, select the HBF Known Gap fee from the list of fees on the right. Note: you will need to right click on the last custom fee in the list in order to see the HBF Known Gap fee you have added if it does not appear in the list
- When the claim is sent, it will be converted to an Agreement claim in the background and will come back with an underpayment from the fund when processed
- Receipt the part-paid amount from the fund & re-assign the invoice to the patient so they can pay the gap amount
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