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.
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 the 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 of $500 is entered into the Max Known Gap box.
Due to the change in the way AHSA now requires the gap to be calculated, you must now ensure the 'Per Item' checkbox is not ticked. You will need to do this for all AHSA funds you have in Genie. In doing this, it will allow Genie to calculate the gap amount correctly per item respective of AHSA rules.
From 1 July 2020, AHSA have changed their rules respective to billing under Access Gap Cover. 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|
|Ph||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 Access Gap Cover rules will apply. In this case, you may be required to adjust your gap amount when creating this invoice.
Applying the old rules when claiming
For services rendered pre-July 2020, you should see a Charge Gap checkbox on the right of your ECLIPSE voucher window. If you have configured your AHSA fund to apply the new rules, this should default to reflect $500.00 in the 'Maximum' field. To ensure Genie calculates the old gap correctly, select the 'Custom' radio button, enter in the gap amount of $400 and tick 'per item' as shown below.
You can then add the items to the invoice as usual, and Genie will calculate the appropriate gap amount using AHSA's old co-payment rules. For more information on ECLIPSE claiming, see our Sending ECLIPSE Claims article.
If you are creating an invoice for a manual claim, the process to calculate the gap rate is slightly different. After creating the invoice as you normally would - selecting the health fund and adding the relevant items, click the Add Known Gap button to the right of the invoice window.
After clicking this button, you will be presented with a window allowing you to enter in a gap amount. This may show as $500 if you have configured your AHSA health funds to reflect the new Access Gap Cover rules. In its place, enter in $400 and tick The Maximum Gap is Per Item then click OK.
This will adjust the gap for this invoice only and will allow Genie to accurately calculate the appropriate gap amount based on the rules prior to 1 July 2020.
How is the old rule calculated?
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).
Example Scenarios prior to 1 July 2020
Below are some examples of how patient gap amounts are calculated prior to the new Access Gap Cover 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|