Response to Unleashing the Potential of our Health Workforce: Scope of Practice Review –– Issues Paper 1

According to information that the APS has received from AskMBS: 

There are no legislative requirements on the content of referrals for Better Access services. The Department of Health and Aged Care understands that referring practitioners will use their professional judgement to determine the information required in referrals for each patient to suit their needs and best support their treatment. However, given the important part referrals play in supporting the aims of Better Access, the following principles can be considered by treating providers when receiving a patient referral for Better Access services. 

• Referrals should include a sufficient level of information to effectively treat the patient in line with their clinical need, as initially assessed by the referring practitioner.  
• Referrals should provide certainty and clarity for both patients and practitioners in relation to the course of treatment to be delivered under the referral. 

 See the below questions for further important advice on referral content.

The Department of health and Aged Care state that a referral should include the following and that referrals with this content will assist in the case of any auditing undertaken: 

• the patient’s name, date of birth and address;  
• the patient’s symptoms or diagnosis;  
• a list of any current medications;  
• the number of sessions the patient is being referred for (the ‘course of treatment’);  
• a statement about whether the patient has an MHTP or a psychiatrist assessment and management plan; and  
• a statement about whether the referral can be used for group therapy or individual therapy. 

If a psychologist receives a referral that contains all of the above details, they can be confident that they have enough information to support the provision of service, and are meeting their requirements to do so.   

The latest Medicare Benefits Schedule advice around referrals advises that a referral for Better Access services should specify the number of sessions a patient is being referred for.  Where a referral is received that does not specify the number of sessions, or specifies a number of sessions above the maximum allowed for a course of treatment or calendar year, the Psychologist can use their clinical judgement to provide services under the referral which is in line with the maximum number of sessions allowed for the course of treatment, and the year. 

AskMBS provided the following advice where referrals do not contain the information above: 

While we understand that allied health providers do not wish to repeatedly contact the referring practitioner for clarification, under Medicare arrangements, it is up to the provider delivering the service to ensure that they meet all the item requirements prior to claiming a Medicare benefit. The psychologist providing the service must be satisfied that the document received supports the provision of referred services. 

AskMBS recently provided the following clarity on this question: 

A referral for services under a Chronic Disease Management (CDM) plan cannot be used to support the provision of Better Access services. It is possible to provide psychological services under a CDM, but these are claimed under a different item number and have a range of requirements that differ from Better Access items.  

The referral letter can be directed to the psychologist by name or may be addressed generically to ‘the psychologist’. According to advice from Medicare, 

“The legislation does not require that a referral should be addressed to a named health professional. If a referral is addressed to one provider, the patient is not obliged to go to the same practitioner. They can see another practitioner in the same discipline to provide the psychological service.” 

No. “A referral is valid until the referred number of sessions have been completed, regardless of whether a patient chooses to change their allied mental health provider.” See: Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS fact sheet for professionals (health.gov.au) 

A new referral is only required once a client has completed the number of sessions on their referral (up to a maximum of six sessions per referral).  For example, if a client had accessed two sessions, towards the end of one calendar year, and the referral allowed up to six sessions, the client has four sessions that can be accessed in the new calendar year before a review by the GP needs to be undertaken.  However, these four sessions will count towards the client’s allocation allowable in the new calendar year.

On occasion psychologists will encounter situations where a client is referred under Better Access for treatment of a condition that does not meet the criteria of the program.  In a Medicare audit situation, where services are provided to a client with an invalid referral under Better Access, the psychologist may be required to pay back funds received from Medicare. 

Receiving an invalid referral under Better Access requires sensitive management. Where possible, it is best to speak to the referrer before the client attends their first session in order to minimise any distress the client may feel. However, where the client presents for their first appointment with the invalid referral, the psychologist should sensitively and carefully explain the reason why the issue of concern listed in the referral does not meet the requirements to receive a Medicare rebate under Better Access. The psychologist should be prepared to discuss treatment possibilities with the client to ensure that they have options. 

It is good practice to follow up with the referrer to understand whether the client has been able to engage with an appropriate service, what the outcome was, note the decision on the file and close the file. This is also in line with best practice as it may prompt the referring practitioner to follow up with the client to help prevent them falling through the cracks or disengaging from services. 

A psychiatrist or paediatrician in private practice can directly refer their private patients for services from a psychologist as long as they use their 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. A psychiatrist or paediatrician may complete an assessment and treatment plan, however, unlike the arrangements for a referral from a GP (where a GP Mental Health Treatment Plan must be completed), there is no formal requirement that they demonstrate completion of an assessment and treatment plan.

Psychologists in private practice occasionally receive referrals from general practitioners (GPs) for clients who do not present for services, or make an initial appointment but do not keep it. 

There are no specific Medicare stipulations about how to manage the referral letter when the client does not present.  Consequently, it is important for psychologists to have a clear policy and procedures about how they handle the intake process, which might include the following principles: 

• Keep referral documentation in a locked filing cabinet or password protected computer, as you would any other confidential client record. 
• Maintain the record in line with your record keeping obligations (see Record keeping: Ethical guidelines | APS (psychology.org.au))  
• Attempt to contact the client to find out if they are still seeking your services. 
• A clear policy regarding the length of time you hold the referral before providing feedback to the referrer that the client has not sought services.   
• Log a brief description of the process undertaken in your client management system or diary for those clients that did not present for services. 

The client may not meet eligibility criteria for referral under the CDM item number. CDM items are for people with chronic medical conditions and the psychological treatment needs to relate to that medical condition (see Medicare items for Chronic Disease Management (CDM) | APS (psychology.org.au)). If the client has a mental health condition only, or if they have a dual diagnosis but you are providing interventions for their mental health condition, they should be managed under a GP Mental Health Treatment Plan and the Better Access items. The client would not meet the eligibility criteria for access to the CDM items which must be directly related to management of the patient’s chronic condition/s. 

The only instance where a client might be managed under both a CDM Care Plan and a Mental Health 

Treatment Plan is where the client is being treated for both a mental health condition and a separate (or related) chronic medical condition. For example, a client presenting with depression, heart disease and diabetes could receive targeted psychological interventions for depression under Better Access and psychological interventions targeting lifestyle behaviour modification and medication adherence under the CDM items. 

Similarly, a client presenting with post-traumatic stress disorder (PTSD) following a motor vehicle accident, who also has significant spinal damage and chronic pain, could receive treatment for the PTSD under Better Access and additional psychological treatment for chronic pain could be delivered as part of team care arrangements under the CDM initiative.