A Medicare rebate for services provided by a psychologist will not be paid under the following circumstances:
It is important to note that before a rebate can be paid for psychology services, Medicare Australia must have already received a claim for direct payment for the relevant GP Mental Health Treatment Plan item or other relevant medical practitioner referral item. If these GP Mental Health Treatment Plan or referral items have not been received by Medicare Australia first, a rebate for psychological services will not be paid.
Psychologists providing Medicare rebateable services may set their own fees but the Medicare rebate for each item is a set amount. However, if a psychologist chooses to direct bill Medicare for a service (i.e. bulk bill), the Medicare rebate for that service must be accepted as the full fee for that service. Psychologists are encouraged to bulk bill clients who are Health Care Card holders.
The Australian Government sets the Medicare schedule fees and indexes these at 1 November each year. For the psychology items, the Medicare rebates are set at 85 per cent of the schedule fee.
The client is responsible for paying any charges in excess of the Medicare benefit for items under this initiative. However, these out-of-pocket costs will count towards the Medicare Safety Net for that client.
It is important to note that if the psychologist bulk bills the client, no additional fee can be charged for the service. If a fee is being charged for the service, the account must be addressed to the client who received the service, as per the usual practice. The client and the private organisation would then need to work out their own financial arrangements for how the bill is to be paid.
No, only psychologists who hold full (‘general’) registration with the Psychology Board of Australia are eligible to provide psychological services under Medicare. Students who are under the supervision of fully registered psychologists are NOT eligible to provide psychological services under Medicare (unless the student is already a fully registered psychologist).
Yes. In addition to psychologists, social workers and occupational therapists with mental health expertise are able to provide the Focussed Psychological Strategies (FPS) Medicare items. Social workers and occupational therapists must meet certain mental health competency criteria set by their respective professional associations in order to provide the items. The schedule fees and rebates for FPS items provided by social workers and occupational therapists are set at a lower level than those for FPS services provided by psychologists in recognition of the additional years of training required for psychologists.
Allied mental health services provided under the Better Access initiative are expected to be for the purpose of providing treatment to eligible clients with an assessed mental disorder. Some assessment activity may, however, form part of the initial consultation with the client, for example, to enable the practitioner to confirm and refine a differential diagnosis of the client or to identify a baseline for establishing the client's progress in response to the treatment provided.
It is anticipated that any assessment provided will be appropriate to the client's presentation and the likely condition to be treated, and will be necessary in informing and directing provision of treatment to the client. Any assessment should occur in preparation for treatment of the client and generally should not extend beyond the initial consultation with the client.
These guidelines, provided by the Department of Health and Ageing, apply to both the ‘Psychological Therapy' items (clinical psychologists) and ‘Focussed Psychological Strategies' items (psychologists). Initially, assessment services were restricted to the items provided by clinical psychologists.
Psychological services under Medicare are specified as ‘professional attendance’ and as such require face-to-face attendance. Other methods of service delivery, such as providing psychological services over the telephone, internet, or via video link, are not allowable under the MBS psychology items. The implications of this for providing services to clients in rural and remote locations have been brought to the attention of the Department of Health and Ageing and the APS continues to advocate for changes in this area.
A valid Medicare service requires the ‘identified patient’ to be present, so a session cannot be conducted with the child’s parents alone under the Better Access Medicare initiative. The discrepancy between best practice psychological assessment of a child and allowable services under Medicare has been been brought to the attention of the Department of Health and Ageing and the APS continues to advocate for changes in this area.
The Medicare items related to out of office consultations can be used to provide services at a client's home or in the community where it is inappropriate or not possible for treatment to be conducted in a consultation room. Use of the out of office item need not be restricted to cases where the location of treatment is prescribed by the therapy (e.g., treating a client with agoraphobia at home), but the diagnostic indications must be appropriate and the treatment provided must be acceptable. An example of this would be working with a terminally ill client at home.
Residents of aged care facilities are NOT eligible to receive psychological treatment under a GP Mental Health Treatment Plan unless they meet one of the following conditions:
If the aged care resident meets one of the above criteria, an ‘out of office' consultation can be charged if the session occurs outside the usual consulting rooms.
Residents of aged care facilities can be seen under the Chronic Disease Management items, where GPs are able to contribute to care plans for residents of aged care facilities using Medicare item 731. In this case, the resident's GP can contribute to the care plan prepared by the facility and the resident is eligible for referral to allied health services, including services by psychologists.
A child under the age of two years may receive services under the Better Access initiative if they have been assessed as having a mental health disorder and have been referred by a psychiatrist, pediatrician or GP under a Mental Health Treatment Plan. The Treatment Plan must be written for the child (not the parents) and the child must be present during the sessions for the rebate to be paid.
In order for a GP to refer a client for psychological services under the Better Access to Mental Health Care initiative, the GP must first complete a detailed assessment and diagnosis of the client. The GP must then prepare the GP Mental Health Treatment Plan, which includes documenting results of the assessment, client's needs, goals and actions, referrals and required treatment/services, and a review date. There is no particular form that is used for preparing the Mental Health Treatment Plan. Clients are encouraged to book a longer session with their GP if they are requesting a referral for psychological services, in order to enable the GP to complete the assessment and GP Mental Health Treatment Plan.
Further information on the GP Mental Health Treatment Plan is available from the Australian Government Department of Health and Ageing .
Clients continue to be eligible for referred services while they continue to be managed by their GP under the relevant GP Mental Health Treatment Plan (through regular reviews by their GP). A new GP Mental Health Treatment Plan should not be prepared unless clinically required (there is a restriction of one GP Mental Health Treatment Plan per client in a 12-month period).
Generally a new referral for further allied mental health services will be planned by the GP in a face-to-face consultation with the client. This could be as part of a review of the client’s Treatment Plan or as part of a normal consultation. In some instances the GP may consider that a separate consultation is not necessary (for example, having recently seen the client) and may consider that further allied mental health services are required based on their knowledge of the client and feedback from the treating provider. Decisions regarding referral for further services should be documented in the client's record.
Where a client has had a GP Mental Health Treatment Plan developed by a GP who is no longer managing the client's care, the new GP should attempt to access the client's existing plan from the previous GP and update the plan using the GP Mental Health Treatment Plan Review item. If this is not possible and the GP considers that exceptional circumstances apply, the GP could develop a new GP Mental Health Treatment Plan within the usual minimum period of 12 months. However, there should be clear reasons why a new plan needed to be developed.
Clients who are being managed by their GP under a GP Mental Health Treatment Plan who need to access further referred services during a new calendar year do not need to have a new Treatment Plan prepared (unless required by the client’s clinical condition, needs or circumstances).
A new referral for allied mental health services may be provided by the GP in the new calendar year where a client has used all previously referred services and the GP considers that the client requires additional allied mental health services (up to the calendar year entitlement of 10 sessions or 16 sessions for eligible clients under the exceptional circumstance in 2012 ). As noted above, it is not necessary to prepare a new Treatment Plan just to make a new referral for services.
The Mental Health Treatment Plan and referral for psychological services must be developed by the client's referring GP and only by the GP. Under no circumstances can a psychologist write the Treatment Plan.
Psychologists who are providing services under the Medicare Benefits Scheme (MBS) may be subject to a compliance audit by Medicare Australia. These audits may be ‘random compliance audits’ or may be conducted on the basis of an analysis of Medicare data and the identification of practitioners whose billing patterns differ from those of their peers (e.g., high billing patterns).
These audits are conducted to check that the services that have been claimed under Medicare have actually been provided. The audit for psychological services may be conducted either by phone and letter or as part of a face-to-face interview. Medicare audits do not involve disclosure of any personal client information regarding the nature of the referral or the treatment that was provided. Nor are they linked to the clinical relevance of the service. They simply address any concerns regarding billing for the service.
Compliance audits are conducted across all service provider groups in the entire MBS program as part of Australian Government requirements. Approximately 2,000 random compliance audits are conducted every year. Although in auditing some professional groups clients may be contacted to verify that the services were received, Medicare has a policy that clients of psychologists who have received services for a mental health problem are not contacted.
Medicare Australia also conducts more detailed ‘research audits’ to determine compliance with the requirements of various MBS programs. The Better Access initiative is not currently subject to a research audit and this will not occur without the APS being consulted and notified. However, for Medicare Australia auditing purposes, a requirement of providing services under Medicare is that for each client seen under the MBS, psychologists are required to retain documentation of the medical practitioner’s referral for each set of sessions and to ensure that all reporting requirements are met. Medicare requires that documentation be kept for 24 months from the date the first service under that referral was provided.
Clients can receive up to 10 individual psychological services in a calendar year. The maximum of 10 allowable services includes any other psychological services provided either by other psychologists (Focused Psychological Strategies (FPS) items or clinical psychology items), or by other eligible social workers or occupational therapists (FPS items), or by GPs (FPS items). However, services received under the chronic disease management (CDM) initiative are not counted in the 10 allowable Better Access sessions, so clients who have received services under the CDM initiative may be eligible for 10 services under the Better Access initiative. Please note that services provided under the Access to Psychological Services (ATAPS) program should NOT be used in addition to the maximum allowable Better Access items. In addition to the allowable maximum of individual psychology services under Better Access, clients can also receive up to 10 group session psychology services in a calendar year. The maximum of 10 group services includes clinical psychology items, and FPS items provided by psychologists or eligible social workers or occupational therapists.
To ensure rebates are paid to clients, or that you will receive bulk billing payments, remember to check with your clients and/or Medicare Australia as to the number and types of psychological Medicare services they have received in the calendar year so far.
Early in 2012 the Government announced interim arrangements to reinstate the ‘exceptional circumstances’ sessions to enable a period of adaptation. The interim arrangements only applied for a transitional period from 1 March 2012 to 31 December 2012.
The maximum number of rebatable sessions per calendar year under the Better Access initiative is 10 sessions. After the maximum number of allowable sessions has been reached, clients will not be eligible for any further Medicare rebates for treatment provided by a psychologist until the new calendar year.
Referrals for allied mental health services remain valid for the stated number of services on the medical practitioner’s referral. Where these referred services are not used during the calendar year in which the client is referred, the unused services may be used in the next calendar year, where they will count towards the maximum number of services able to be received during that year.
For example, if a GP prepared a GP Mental Health Treatment Plan for a client in November and referred the client for six allied mental health services but only two of these services were provided by 31 December, the remaining four referred services would still be valid into the next calendar year. The remaining four services could be provided the next year using the original referral but would count towards the client’s new calendar year limit for allied mental health services.
Clients cannot use their private health insurance ancillary cover to pay the gap between the Medicare rebate and the charge for psychological services.
Clients need to decide if they will use Medicare or their private health insurance ancillary cover to pay for psychological services they receive. Clients with this insurance can either access rebates from Medicare by following the claiming process or claim where available on their insurer's ancillary benefits. It is the client's choice, not that of the health insurance company or the psychologist.
Where the client chooses to claim against their health insurance (gets a better rebate, has exhausted the 10 sessions, or does not have a specified mental health disorder), the psychologist can assist the client and the health insurance company by not using the Medicare item numbers and marking on the account 'Not claiming under Medicare'. Such a process will ensure that any confusion will be removed for the private health insurance company and the client's claim will be processed promptly. No such confusion will arise where electronic claiming (HICAPS, IBA) is being utilised, as the very act of claiming against one of the collaborating health insurance companies electronically should make the client's intentions clear.
Clients need to decide if they will use Medicare or their private health insurance ancillary cover to pay for the psychological services they receive. Clients with health insurance can either access rebates from Medicare by following the claiming process or claim where available on their insurer's ancillary benefits. It is the client's choice, not that of the health insurance company or the psychologist.
Where the client chooses to claim against his/her health insurance (for instance, may receive a better rebate, has used the allowable 10 sessions, or is not eligible for services under the Better Access initiative), the psychologist can assist the client and the health insurance company by not using the Medicare item numbers and marking on the account 'Not claiming under Medicare'. Such a process will ensure that any confusion will be removed for the private health insurance company and the client's claim will be processed promptly. No such confusion will arise where electronic claiming (HICAPS, IBA) is being utilised, as the very act of claiming against one of the collaborating health insurance companies electronically should make the client's intentions clear.
Please be aware that the Private Health Insurance Ombudsman (PHIO: www.phio.org.au) provides an independent service to help consumers with health insurance problems and enquiries. The Ombudsman can deal with complaints from health funds, private hospitals or medical practitioners. Complaints must be about a health insurance arrangement.
The psychology Medicare items do not apply for services that are provided by any other Commonwealth- or State-funded programs. However, where an exemption under subsection 19(2) of the Health Insurance Act 1973 has been granted to an Aboriginal Community Controlled Health Services or State/Territory Government health clinic, these items can be claimed for services provided by eligible allied health professionals salaried by, or contracted to, the service as long as all requirements of the items are met, including registration with Medicare Australia. These services must be bulk billed (that is, the Medicare rebate is accepted as full payment for services).
No. Any treatment services provided through an organisation funded by the State or Commonwealth can NOT be paid for via Medicare. This is stated categorically under Section 19(2) of the Health Insurance Act 1973. The intention of this section of the Act is to preclude multiple payments being made through separate governing bodies for a single clinical service. State or Commonwealth organisations that provide services that are funded by Medicare should seek their own legal advice as to whether their current or proposed arrangements infringe the Act.
According to the Medicare Benefits Schedule, November 2011, “The referral may be in the form of a letter, or note to an eligible allied health professional signed and dated by the referring practitioner. The allied health professional must be in receipt of the referral at the first allied mental health consultation.”
In direct correspondence with Medicare Australia and the Department of Health and Ageing, the APS has also been provided with the following additional information regarding what constitutes a valid referral.
A psychiatrist or paediatrician in private practice can directly refer their private patients for services from a psychologist as long as they use their private Medicare Provider Number and charge the appropriate Medicare attendance item for the referring consultation (specialist psychiatrist Medicare items or consultant physician paediatrician Medicare items). Medicare Australia must have processed a claim for the referring consultation before a rebate for the psychology services can be given. Unlike under the arrangements for a referral from a GP (where a GP Mental Health Treatment Plan must be completed), there is no formal assessment item that psychiatrists or paediatricians must have undertaken other than consulting the client. Psychiatrists and paediatricians operating in the public sector cannot refer public clients under the Better Access initiative.
The APS website provides a list of psychologists who are eligible to provide services under the various Medicare initiatives - Better Access to Mental Health Care, Pregnancy support counselling, Children with autism or any other pervasive developmental disorder, and Chronic disease management. The list is searchable by both location and the practitioner's name. The list can be found at www.psychology.org.au/MedicareProvider.
APS members who are eligible to provide Medicare services who wish to be included on the Medicare Provider List will need to register online. The process is as follows:
By adding a Medicare Australia Number(s) you accept that your name will be placed on a list that will be available to be used by GPs, other professionals or members of the public.
The amount of detail in the report to the referring medical practitioner is not specifically mandated. The Medical Benefits Scheme Explanatory Notes do state that the report should include information about assessments carried out, treatment provided and recommendations on the future management of the client's disorder. In meeting these requirements, the psychologist should use clinical judgement on what information is appropriate to include in the report.
Psychologists must provide a written report to the referring medical practitioner following the first six psychological services or on completion of that course of treatment (which will be a maximum of six services, but could cover less than six services depending on the nature of the referral).
The amount of detail in the report to the referring medical practitioner is not specifically mandated. According to Medicare Australia the report should include information about:
The client should be reviewed by the referring medical practitioner after the first six psychological services and following receipt of the psychologist’s report. The review will determine whether the second set of four psychological services is required. In some instances, a referring medical practitioner may authorise the second set of four psychological services without reviewing the client in person. Where this occurs, the psychologist should document any telephone conversation with the referring doctor and seek written authorisation from him/her to ensure that the validity of the second set of four psychological services can be substantiated at a later date, if required.