Medicare Confusion

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We have need to call Medicare to clarify some issues regarding EPC referrals & AGAIN we have had different opinions that a referral lasts 12 months while others have said 24 months. We have also had the advice that if a referral is received say July 1st for 5 visits that we can use the 5 visits before the end of the year & as the referral lasts 12 months, we could use 5 visits again up until the 30th June of the next year without getting a new referral (this is accurate statements for different Medicare staff). If the referral lasts 24 months & again it starts say 1st July we have also been told that we can use 5 visits this year, 5 visits next year & 5 visits the year after agin up to the 30th June (15 in total without a new referral).

If this is written in a confusing way, then I apologise. Is anyone able to clarify the situation? Documentation we have says whatever the GP refers, once used they have to get a new referral. Verbal information from multiple Medicare staff says something totally different.

 

Unfortunately the is a unnecessarily complex referral process, since day one.

I am sure you are not alone, and certainly most GPs also fail to understand the situtation. Having Medicare not understand it either is symptomatic of the unnecessary complexity of it all (viva DVA!).

The process is as such;

* Any GP referral under a CDMP is considered valid until the END OF THE FOLLOWING YEAR OF THE REFERRAL.
* HOWEVER, a maximum of 5 allied health services can be claimed in association with a CDMP in ANY GIVEN YEAR

So, in practice this means that a new referral in say October 2010 (assuming 5 podiatry visits nominated) allows for 5 visits to be potentially be available before the end of 2010. BUT, the referral is considered valid until the end of 2011...so the visits can be used in 2010 or 2011.

In reality, if the patient has sufficient needs, it would be appropriate to request a new 'referral' (this is a tokenistic version of the original referral attached to the CDMP) for a new round of 5 visits in 2011 - that way the patient can obtain the maximum number of visits for which they are entitled to you.

Confused?

It only took me about 3 years to work this out.

The bottom line is, 5 visits per calender year. The referral is actually fairly meaningless in a way.

LL

 

Markleigh. we have had the same problems as you medicare staff seem to say different things every time we call them.

as i understand it you can only have 5 visits per year from jan to dec and only what the GP has put on referral.
So if you do start a new referral say in july for 5 visits you can use 5 visits by december then get new referral for another 5 visits from the following jan.

i have had several discussions with Gp`s and practice nurses on this and this is how we all understand it. they do not last 24 months. if some one has used 2 out of their 5 visits and gone past the 12 monthly referral date they cant use them they have to get a new referral.
Hope this helps, if you have any more questions ask me we have been trying to work it out for the last 5 to 6 years.

Jaynes

 

Perhaps I can clarify further. (Or this might confuse you even more!)

Based on my understanding and disucssion with Medicare and Practice nurses, the system works as follows:

The date of referral is the reference point from when the 5 visits can be used within the calendar year (Jan 1st to Dec 31st). (These are MBS items 721/723/731.)

The period of referral is 24 months, from the reference point.

5 Visits in a calendar year are able to be used in any combination - ie 5 Podiatry or 3 Dietician + 2 Physio.

So an example might be:

- Mrs X has a Medicare Plan Podiatry referral from 1/3/2010 for 5 Podiatry visits. She is treated every 8 weeks for 2010 and 5 visits are used up.
- On 1/1/2011 Mrs X. now has 5 new visits to use, until the end of the year. So in order to now use up Mrs. X's visits, you can only see her every 10 weeks.
- On 1/1/2012 Mrs. X has 5 more visits, but she can only use the 5 on her current Medicare Plan until 29/2/2012. After that she must get a new Medicare Plan. So if Mrs X developed an ulcer and needed to be seen 5 times to heal it from Jan 2012 until the end of Feb 2012 then she could get a new Medicare Plan, but she couldn't use any of her Podiatry visits until Jan 2013 as she has used up all of her 5 vists for the calendar year.

Making sense? I took me 1 whole day of research to discover this, but it works.

A few other points I find helpful:

- GP's can review a Medicare Plan from 6-12 months after that date of referral to assess the success of the plan. That review is not a new reference point (date of referral), but the referral date can be used for billing and claiming purposes until the end of the 24 month referral period.
- A new Medicare Plan can be made any time 12 months after the date of referral - I find this the simpilest way to avoid accidental over-claiming.
- Some patients might have more visits available depending on reviews, cessation of other services (eg saw Diabetes Educator for 2 vists in late 2010 and now doesn't need to see until 2012) allowing for more Podiatry visits.
- If unsure of how many services left or referral dates, check with referring GP and his staff (the practice nurses are the one who do most of the paperwork so they understand Medicare Plans the best) or with Medicare to see how many have been claimed.
- If possible, try to get as many Medicare Plans for early in the year, as the reference points and amount of treatments available are easier to play with.

Phew! Hope all that makes sense!

 

Thanks everyone. I appreciate your replies. The bigger issue is perhaps the mis-information & confusion that comes from Medicare itself - half the workers there seem to be more confused than us which really doesn't help.

 

My understanding is 5 in a calendar year and 5 in a 12month year.
So if you have a referral in June 2011, you can use 5 visits up in 2011 and the visits start over again in 2012 where you can start again. This is what you have mentioned in your first post.

I thought it strange, have rung Medicare a few times and it seems to work the best this way.

I have been using this method since 2009 and all claims have been approved.

Has anyone got any information regarding how successful the trial for 8visits a year? My clinic is 90% epc's so I'm interested to know

 

Yep, referrals ARE valid for 2 years from the intial referral date.

try to streamline new referrals into the first few months of the year- those that come in after July are a pain to explain the system to.

We now contact the GP clinic if they send a new referral for a Pt when there is already one in place that is not completed/used up. Often pts tell the GP clinic they have been to the podiatrist (and haven't), then the GP clinic wonders why I haven't written a letter to them. This makes it all much clearer and bypasses the confusion that Pts create.

 

after reading the first few posts everything was making sense - then i read on and im all confused again! It seems that everyone is recieving conflicting information from Medicare. I think a spokesperson from Medicare at the next pod conference to explain in detail and field questions would be ideal

 

I agree with iliubinas, either a spokesperson at the conference or a Professional development session on medicare is the best way to clear up the confusion

 

Hi All,
The EPC question has more answers than who will win the football on saturday and why.

No two people from Medicare will give you the same answer to any given question about EPC.
My understanding, at the moment, is.

A GP referral is good for up to 12 months or as indicated on the referral.
If it is an EPC referral it can be for up to a total of 5 allied health visits in that 12 months.
A patient can only have 5 allied health EPC visits per calendar year.
Visits not used in one calendar year can be used in the next calendar year but if used in the next calendar year they count to that years total. (A gotcha for those who bulk bill)

This appears to be what the Medicare computer will allow when the PX makes a claim or if we try to bulk bill. Medicare folks may tell you different stories but it is their computer that makes things happen.

 

Thanks...

Guys

Im just going to work on the 5 visits per calendar (from issuing the referral)