Gaps and out-of-pocket charges

Gaps and out-of-pocket charges

Here are some tips on when you can and can't charge gaps and out-of-pocket expenses with Cutting Edge.

It is important to note that under current legislation, both the practitioner providing the services and the person who manages their billing and claiming have a shared liability for any debts identified during compliance audits. See Shared Debt Recovery Scheme for further information.

Claim Type
Notes
Bulk Bill
No additional charges permitted. Under Medicare legislation, when a patient assigns their Medicare benefit rights to the health professional who rendered the services via bulk billing then that is payment in full and there must be no other charges of any kind.
Medicare Claim
With a Medicare claim you may charge an out of pocket. Be aware that where the invoice is paid in full then the rebate will be sent to the patient. In all other cases the rebate will be sent as a cheque via the patient (Pay Doctor Via Claimant). For this reason we recommend only using Medicare claims for fully paid accounts. 
Department of Veterans' Affairs
When billing DVA, you must never charge an out of pocket expense. DVA will pay according to their schedule of fees.
No Gap (NG) claims to health funds (BUPA, HCF, HBF WA)
As the name suggests, you shouldn't charge a gap where you are registered with the fund as a No Gap provider with these funds. Funds that have No Gap arrangement pay a higher rebate where the patient isn't charged a gap. Your invoices must show all charges. Separate invoices for booking or admin fees are not compliant with this requirement. If you charge a gap in this situation then the fund decreases the rebate to the MBS schedule of fees.
Known Gap (KG) claims to health funds
Many funds define a maximum gap to be used with their schedule of fees. You may change up to that maximum gap without affecting the fund rebate. If the gap exceeds the maximum allowed them the fund rebate drops to MBS level of fees. NOTE that for BUPA and HCF their KG schedules have a lower rebate than their NG schedules.
The maximum gap is $500 for most funds.
NIB Gapsure only allows gaps on anaesthetic invoices with a base item of 5 units or more. 
Grand United Health's gap is $400.
There's no maximum gap for Latrobe or Mildura District Health funds.
HBF WA (but not other states) has a number of different arrangements.
Third Party accounts
Work Cover and motor vehicle accident claims should be sent to the insurer or employer, patients shouldn't be charged any fees.



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