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.
Before you begin
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 before generating any quotes.
You should also ensure you are familiar with which health funds are Participating AHSA members.
For Genie to automatically calculate that Max Known Gap for a fund, then this needs to be set in the Health Fund window. To do this, navigate to Open> Billing Items and select Health Funds in the top right corner. Locate your fund and double click to open the fund profile. Ensure that the correct gap is entered into the Max Known Gap box.
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 becomes the AMA fee - 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).
For more information about Access Gap Cover, including an upcoming change to the co-payment rule in July 2020, please refer to the AHSA website via this link.
Below are some examples of how patient gap amounts are calculated, depending on the AMA fee and health fund rebate for each item:
|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|