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​​Intensive Care Fees

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An Intensive Care Unit (ICU) is a specialised area in a hospital where patients are admitted because they are very ill and/or require close observation and monitoring by highly trained doctors and nurses. Patient care often involves complex life-support measures such as breathing machines (ventilators), drugs and/or pumps to support the heart, and kidney dialysis.
 
In Australia, intensive care specialists (‘Intensivists’) need to complete formal specialist training in intensive care medicine (minimum six years) in addition to their medical degree.
 
In addition to caring for patients within an ICU, Intensivists have become the ‘safety net’ for hospitals, providing a wide range of acute care services throughout the hospital, such as emergency calls, resuscitation services (such as cardiac arrest), and ward consultations.
 
The provision of safe and high quality care to patients in general hospital wards is now highly dependent upon a functional and effective ICU supported by highly trained Intensivists.
 
An Intensive Care Unit may also be referred to as:
Critical Care Unit
Intensive Therapy Unit
A High Dependency Unit (HDU) or Step Down Unit (SDU) usually forms part of the ICU​

The Federal Government, through the Department of Health and Ageing, each year sets fees which determine the amount the Government will contribute for most medical services that are rendered to patients in Australia who are eligible to receive Medicare benefits. The fees are published each year in what is known as the ‘Medicare Benefits Schedule’ (MBS), and the fees are known as the Schedule Fees. For patients admitted to private hospitals, Medicare pays 75% of this fee. For those patients who elect to have private health cover, their health fund contributes the remaining 25% of the MBS fee.

In the Private sector, a doctor may choose to charge in excess of the Schedule Fee, potentially leaving a patient with an out-of-pocket expense. That is, the patient will need to pay a ‘gap’.
 
Since 2000, many health funds have offered to pay doctors a loading in excess of the fee set by Medicare rate for services they provide, on the condition that they don’t charge the patient a separate out-of-pocket gap.
 
This is frequently done in the context of simplified billing, where doctors send their bills directly to the patient’s health fund, who recover the Medicare entitlement on behalf of the patient, and then contribute their own component to fully pay the bill. This is administratively simple, and relieves the patient and their family of the burden of filling out forms and having to coordinate and forward the payments. This means that while a patient is recovering from their surgery or illness, all medical bills are dealt with and a final statement from the health fund is sent to the patient for information only.
 
When Health Funds introduced these (‘no gap’) loadings in 2000, the amounts were based upon historical billing patterns by different specialist groups. That is, those who had previously charged higher gaps were ‘rewarded’ with higher loadings. As most Intensivists did not charge gaps at that time, the loadings were set at very low levels.
 
As an example, most Anaesthetic services are offered a loading of around 70%, as an incentive for Anaesthetic doctors not to charge gaps.
 
In addition, most Surgical operations are offered a loading of 40-65%, as an incentive for Surgeons not to charge gaps.

Historically, the vast majority of Intensivists around Australia have not charged their patients gaps. However, many Intensivists believe that the current Medicare rebates for their services are clearly inadequate, and are well below those recommended by the Australian Medical Association (AMA) as being fair fees. The Australian and New Zealand Intensive Care Society (ANZICS) has been negotiating with the Federal Government for several years to improve the rates, but without success.
In addition, the loading offered by most health funds for Intensive Care services is only between 2 to 12% above the Schedule Fee, and varies widely between different health funds. This is significantly less than that offered to other specialists (see Patient Billing).
ANZICS and individual Intensive Care Units have tried negotiating with a number of the private health insurance funds to increase their loading, again without success.
Accordingly, some Intensive Care Specialists may choose to charge gaps if they believe that the current payment for their services is inadequate.

Historically, the vast majority of Intensivists around Australia have not charged their patients gaps​
However, many Intensivists believe that the current Medicare rebates for their services are clearly inadequate, and are well below those recommended by the Australian Medical Association (AMA) as being fair fees. The Australian and New Zealand Intensive Care Society (ANZICS) has been negotiating with the Federal Government for several years to improve the rates, but without success.

In addition, the loading offered by most health funds for Intensive Care services is only between 2 to 12% above the Schedule Fee, and varies widely between different health funds. This is significantly less than that offered to other specialists (see Patient Billing).

ANZICS and individual Intensive Care Units have tried negotiating with a number of the private health insurance funds to increase their loading, again without success.

Accordingly, some Intensive Care Specialists may choose to charge gaps if they believe that the current payment for their services is inadequate.

Private health insurance funds may offer to pay Intensivists a loading on top of the Medicare rate for services they provide.

To receive this loading, the Intensivist must agree not to charge that patient a gap - that is, it is an incentive for the specialist to not charge gaps.

The amount of this loading may vary enormously between Health Funds, and even between different Intensive Care specialists with the same Health Fund in the same State.

Examples of Health Funds who offer LARGER loadings for Intensive Care services are:

  • AHSA (WA) - 45%
  • Department of Veterans Affairs (Australia-wide) - 20%​

Suggestions for patients who are to receive treatment in a private hospital include

  • Ask the Intensive Care specialist if you see them prior to a planned admission as to whether you are likely to be charged a gap. This is often difficult as patients do not generally see the Intensivist prior to admission.
  • Ask the doctor (eg surgeon) responsible for your admission to hospital what out-of-pocket expenses you may expect, INCLUDING possible gaps for any care in an Intensive Care Unit by an Intensive Care specialist.
  • Ask the private hospital to which you are to be admitted whether they are aware of any potential gap payments for care received in their intensive care unit. Also read the Admission Information booklet that is often provided as this may also include information on fees.
  • Ask your Health Fund whether you are likely to incur a gap payment for care provided by an Intensive Care specialist at the hospital to which you are to be admitted. This is not the same as the cost of a bed in Intensive Care, which is usually covered by the health fund.

If you are unhappy with having to pay a gap for intensive care services, we suggest you discuss this with your health insurance fund.​

ANZICS strongly recommends that you consider the measures outlined in the section below on Financial Consent if you are considering charging gaps.​

Billing practices may vary slightly between Health Funds, but in general, the following principles apply;

  • Send the full account for the patient to the Health Fund.
  • Send an account for the gap payment to the patient, as well as a copy of this account to the Health Fund as well.
  • The Health Fund will forward their component of the payment to you.
  • The patient is expected to forward payment of the gap to you directly.

The Commonwealth Government and the AMA both strongly encourage doctors to fully inform patients of any out-of-pocket expenses prior to any recommended treatment.

The Health Legislation (Gap Cover Schemes) Act (2000) requires doctors who participate in Gap Cover Schemes to provide written estimates, which in turn must be acknowledged in writing (i.e. signed) by patients. The AMA provides a proforma for such estimates which is available from their website.
 
The legislation accepts emergency treatment as a circumstance in which financial consent is not practicable, but in such cases doctors are required to inform patients of any extra charges as soon as is reasonable after the event.
 
Because it is not usual practice for Intensivists to see patients (including elective patients) prior to their ICU admission, a somewhat modified approach is necessary. After discussion with the AMA solicitor, the following recommendations are made by the ANZICS Practice and Economics Committee and endorsed by the AMA. Intensivists participating in Gap Cover Schemes should pay particular attention to these, as there is a legal requirement in these cases.
 
Elective ICU referrals
 
Regular referrers of elective patients should be informed that it is your usual practice to charge a gap fee, and you should provide an estimate of the typical amount of that gap. It then becomes the duty of the referring doctor to inform the patient of this additional cost. It may be convenient to provide copies of a printed explanation or to incorporate such an explanation in a more general information leaflet, which the referring doctor can provide to patients on your behalf.
 
For infrequent referrers, the recommendations for non-elective referrals are sufficient.
 
Non-elective ICU referrals
 
Under the legislation, these can be regarded as emergencies, but a reasonable effort to inform non-elective patients or their relatives of any gap charges should be made. Suggestions for this include appropriate signage or the provision of leaflets (as described above) in the ICU waiting area, preoperative wards or via the hospital admission clerks. Alternatively, such information can be provided directly by ICU clerical or secretarial staff. Information in writing is preferable, and should include an invitation to discuss with you any concerns about the gap charges. Written acknowledgement or signoff is not essential in these cases.

The Australian Medical Association has developed a Estimate of Medical Fees form. It has clearly been developed for elective surgical admissions, but could be modified for the intensive care setting. It may be particularly useful if provided to patients by the admitting clinician (eg surgeon) prior to admission if intensive care management is considered likely (eg elective abdominal aortic aneurysm repair).
Click here to download the form:

ANZICS Statement on Intensive Care Specialists Providing Services to Patients in Private Hospitals


Background
Intensive care specialists (Intensivists) frequently provide professional services to patients in private hospitals, often as a group practice, to facilitate 24/7 rostering, continuity of care, familiarity, and maintenance of standards required for the safe delivery of care. This statement outlines several matters that Intensivists who treat patients in private hospitals should consider.
 
Rostering
The safe management of intensive care patients calls for Intensivists caring for these patients to be rostered solely to the intensive care unit whilst on duty and immediately available when on call. As mentioned above Intensivists frequently operate as part of a group with a defined roster. Intensivists should be cognisant of the ACCC recommendations for Medical rostering published in July 2004 which can be accessed at www.accc.gov.au.
 
Relationship with private hospitals
Private hospitals should ensure their intensive care units satisfy current recommendations and guidelines stipulated in the Medicare Benefits Schedule Book published by the Australian Government Department of Health and Ageing, including the provision of junior medical staff. In addition to direct patient care, Intensivists frequently provide non-clinical and administrative services to private hospitals, such as, but not limited to on-call availability, support for clinical emergencies, supervision of medical emergency or cardiac arrest teams, hiring and supervising junior medical staff, the development of a number of clinical protocols for use within the intensive care unit and participating in hospital committees. These additional services are over and above contractual obligations to individual patients and as such these services should be remunerated by the hospital in the form of a retainer or other appropriate arrangement. Whilst many options are available and no single option is preferred, Intensivists are advised to seek professional advice about the best structure for their local environment. However, when considering a service agreement with a hospital it
is recommended that Intensivists engage the respective hospital in a contractual arrangement that considers the following:
 
General terms:
1. The duration and terms of renewal of the contract;
2. The duties expected of the Intensivists, both clinical and non-clinical, including appointing a director of the unit to liaise with hospital administration;
3. The responsibilities of the hospital in ensuring adequate facilities are provided to care for patients;
4. Provision of office facilities for the Intensivist on duty and provision of a safe and adequate environment for work;
5. Granting the relevant clinical privileges as appropriate;
6. Clear process for dispute resolution and disengagement;
7.Other items of specific relevance.
 
Financial terms:
1. An agreed remuneration for the Director’s role and other non-clinical duties;
2. A process of invoicing and payment;
3.Clearly define that a clinician’s billing for professional services is a matter between the clinician and their patients.
 
Practitioners’ arrangement
It is recommended that practitioners working as a group consider entering into an agreement that defines and addresses the following:
1. Risk and liability severally, jointly and individually;
2. Individual’s share of income within the practice which may be defined by the number of weeks/days on duty;
3. Mechanism for share distribution;
4. Appointment of a director;
5. Adherence to an agreed Code of Conduct;
6. Terms of inclusion of new members;
7. Terms of termination of members;
8. Voting rights within a group arrangement;
9. Provision for sick and annual leave;
10. Confidentiality;
11. Clear process for dispute resolution;
12. Process whereby a practitioner’s share (wholly or partly) may be handed over, or sold, to another practitioner;
13. Process of dissolution of a group arrangement;
14.Other items of specific relevance.
 
Disclaimer
Whilst ANZICS provides this statement as a guide, it acknowledges the terms of free and fair trade and fully endorses the provisions of the Trade Practices Act 1974. This statement is not meant to provide comprehensive recommendations, but is rather designed to encourage Intensivists working in private hospitals to formalise their engagement with the respective hospitals and amongst themselves.

No Gap
'No Gap' medical billing occurs when:

  • The doctor charges the Medicare fee, or
  • The doctor and the Private Health Fund (either directly or via a private hospital) have an agreement for payment above the Medicare fee and the doctor charges the agreed fee, or
  • The doctor uses an existing Private Health Fund 'product' (such as HBA's Ezyclaim or Medibank Private's GapCover) and does not charge the patient an additional amount.
Gap
'Gap' medical billing occurs when the doctor charges the patient an amount in addition to the Medicare fee, such that the patient receives an out-of-pocket expense.
 
Schedule Fee
The Federal Government, through the Department of Health and Ageing, each year sets fees which determine the amount the Government will contribute for most medical services that are rendered to patients in Australia who are eligible to receive Medicare benefits. The fees are published each year in what is known as the ‘Medicare Benefits Schedule’ (MBS), and the fees are known as the Schedule Fees.