BSBMED302 Readings

The Pharmaceutical Benefits Scheme (PBS) began as a limited scheme in 1948, with free medicines for pensioners and a list of 139 ‘life-saving and disease preventing’ medicines free of charge for others in the community.

Today the PBS provides timely, reliable and affordable access to necessary medicines for Australians. The PBS is part of the Australian Government’s broader National Medicines Policy.

The aim of the National Medicines Policy is to meet medication and related service needs, so that both optimal health outcomes and economic objectives are achieved.

Under the PBS, the government subsidises the cost of medicine for most medical conditions. Most of the listed medicines are dispensed by pharmacists, and used by patients at home.

Some medicines are dangerous to administer and need medical supervision (such as chemotherapy drugs) and are only accessible at specialised medical services, usually hospitals.

What is the PBS?

The PBS Schedule lists all of the medicines available to be dispensed to patients at a Government-subsidised price. The Schedule is part of the wider Pharmaceutical Benefits Scheme managed by the Department of Health and Aged Care and administered by Services Australia.

This schedule is now on-line and updated on a monthly basis. This on-line searchable version contains:

• All of the drugs listed on the PBS
• Information on the conditions of use for the prescribing of PBS medicines
• Detailed consumer information for medicines that have been prescribed by your doctor or dentist
• What you can expect to pay for medicines.

The PBS has been in existence since 1948 and is governed by the National Health Act 1953 (Commonwealth).

Who is eligible for the PBS?

The Scheme is available to all Australian residents who hold a current Medicare card.

Overseas visitors from countries with which Australia has a Reciprocal Health Care Agreement (RHCA) are also eligible to access the Scheme. Australia currently has RHCAs with the United Kingdom, Ireland, New Zealand, Malta, Italy, Sweden, the Netherlands, Finland, Norway, Belgium and Slovenia.

Residents of these countries must show their passports when lodging a prescription to prove their eligibility or they can contact Services Australia and get a Reciprocal Health Care Agreement Card to prove their eligibility. Some overseas visitors may not be eligible for this card.

Only those eligible for the PBS will receive subsidised medication and every time you present your script to the pharmacist, you will need to provide your Medicare card.

Eligible veterans may need to present their DVA card in addition to their Medicare card.

With your consent, the pharmacist may (at their discretion) keep a record of your Medicare number so that you do not have to show the actual card every time you lodge a script

What is the RPBS?

The Repatriation Pharmaceutical Benefits Scheme (RPBS) is administered by the Department of Veterans’ Affairs (DVA), and can be used by veterans who have a DVA White, Gold or Orange Card.

If you hold one of these cards then you are eligible for all PBS medicines, and other medicines listed on the RPBS, depending on your DVA entitlement. All medicines supplied under the RPBS are dispensed at the concessional rate (or free if the patient has reached their Safety Net threshold).

DVA white card entitles you to RPBS and PBS medicines at the concessional rate for a specific medical condition (which is at your doctor’s discretion). You can receive all other PBS medicines at the general rate by showing your Medicare card.

DVA gold and orange cards entitle you to all RPBS and PBS medicines at the concessional rate.

What is the Dental Schedule?

Dentists are not able to prescribe general PBS items, but have a separate Dental Schedule from which they can prescribe dental care medicines for their patients.

What is the Optometrical Schedule?

Optometrists are not able to prescribe general PBS items, but have a separate Optometrical Schedule from which they can prescribe eye care medicines for their patients.

Who is eligible for a concession?

To be eligible for a concessional benefit, you will have one of the following concession cards:

• Pensioner Concession Card;
• Commonwealth Seniors Health Card;
• Health Care Card; or
• DVA White, Gold, or Orange Card.

Some State / Territory governments issue Seniors Cards. These are not considered concession cards for the purposes of the PBS.

Centrelink is responsible for the issue and administration of the Pensioner Concession Card, the Commonwealth Seniors Health Card and Health Care Cards.

The Department of Veterans’ Affairs is responsible for DVA White, Gold and Orange Cards.

There is also a DVA Pension Card which entitles holders to PBS medicines at the concessional rate (but not RPBS medicines).

General benefits apply if you do not have any of the above cards.

What are the current patient fees and charges?

Patient co-payments

The co-payment is the amount you pay towards the cost of your PBS subsidised medicine. Many PBS medicines cost significantly more than the co-payment amount.

From 1 January 2023, you may pay up to $30.00 for most PBS medicines, or $7.30 if you have a concession card. The Australian Government pays the remaining cost (with the exception of brand premiums and certain other allowable charges).

The general patient co-payment amount was reduced on 1 January 2023 from $42.50 to $30.00 per pharmaceutical benefit. The Government has also introduced flow-on changes: a new discretionary increased discounting for specific eligible medicines; and making changes to the Closing the Gap co-payment program.

From 1 January 2023, pharmacists will have the option to provide a discretionary discount to general patients for specific eligible medicines. This is not mandatory, and it is the pharmacist’s choice to provide a discount.

For more information, please refer to the Frequently Asked Questions document here (PDF 362KB) - (Word 620KB).

To be eligible for a discretionary discount the prescription would have to:

• be an ordinary script for a general patient
• have a Commonwealth price in the range above the new co-payment amount of $30.00 and up to, and including, the 2022 co payment amount (indexed). In 2023, the upper threshold amount will be $45.60, following indexation applied on 1 January 2023 to the 2022 amount of $42.50. From 1 January 2024, both of these amounts will be subject to ongoing annual indexation.

The amount counting towards the Safety Net for these prescriptions continue to be calculated in the same way as for non-discounted under co-payment prescriptions.

As PBS medicines can vary in price depending on the pharmacy from which they are purchased, it may be beneficial for patients to compare pharmacy prices for their medicines.

Since 1 January 2016, pharmacists may choose to discount the PBS patient co-payment amounts (concessional and/or general) by up to $1.00. This is not mandatory, and it is the pharmacist’s choice to provide a discount. The option to discount the co-payment amount does not apply for prescriptions which are an early supply of a specified medicine. This provides a minimum concessional co-payment of $6.30, and allows pharmacies to charge general patients $29.00 for a medicine priced at or above the general patient co-payment amount. This allowable $1.00 discount will continue in conjunction with the new increased discount arrangements.

The co-payment amounts will continue to be adjusted on 1 January each year in line with the Consumer Price Index (CPI).

Safety Net

From 1 January 2023, the PBS Safety Net threshold for patients with a concession card will be $262.80 and for other eligible patients it will be $1,563.50.

The same general or concessional Safety Net threshold is applied to a family unit regardless of whether the unit consists of an individual, a couple or a family with dependent children. To be included in the same Safety Net family, the partners of a couple may be married or de facto, and of the same or opposite sex. A couple must be living together on a permanent basis, unless living separately due to illness.

After reaching the Safety Net threshold, general patients pay for further PBS prescriptions at the concessional co-payment rate and concession card holders are dispensed PBS prescriptions at no further charge for the remainder of that calendar year. In order to access the Safety Net arrangements, you need to maintain records of your PBS expenditure on a Prescription Record Form (PRF). These are available from all pharmacies. The value of the actual amount paid will be recorded on your PRF: that is, the general or concessional co-payment amount; the amount paid for under co-payment prescriptions or those who have had an eligible discretionary increased discount applied; and since 1 January 2016, less any allowable discount, up to a maximum of $1.00.

A Safety Net Entitlement card or Safety Net Concession Card can be issued by the pharmacist once the threshold is reached.

For further information about the PBS and Safety Net arrangements, ask your pharmacist, contact the PBS Information Line on 1800 020 613 (free call) or visit the Services Australia.

Public Hospitals and the Safety Net

The Safety Net threshold may be reached using scripts filled at both community pharmacies and out-patient pharmacies at public hospitals – this is called the joint Safety Net. From 1 January 2023, the contribution rate for general patients as out patients in public hospitals in most states and territories is $24.00. In public hospitals where States and Territories are participating in Pharmaceutical Reforms, patients will pay a maximum of $30.00. These amounts are adjusted on 1 January each year.

Items that are priced below the general patient co-payment

For general patients, an allowable additional patient charge can apply. The allowable additional patient charge is a discretionary charge to general patients if a pharmaceutical item has a dispensed price for maximum quantity less than the general patient co-payment. The pharmacist may charge general patients the allowable additional fee but the fee cannot take the cost of the prescription above the general patient co-payment for the medicine.

The fee is currently $3.29 and is adjusted on 1 January each year.

Additional fee for ready prepared items

In addition, if a medicine has a ‘dispensed price for maximum quantity’ less than the general co-payment amount, a Safety Net recording fee may be charged by your pharmacist. This fee must not take the cost of your prescription above the co-payment amount.

Concessional patients do not pay this fee.

This fee is currently $1.31. The amount of this fee does count towards your Safety Net threshold.

What is a Price premium?

A price premium or brand premium, may apply to some medicines and is an additional payment that you pay to the supplier of the specified brand of a PBS medicine. The additional charge does not mean there is any difference in quality between brands.

Importantly all brands have been evaluated by the Therapeutic Goods Administration (TGA) as equivalent. In a very small number of cases a prescriber may direct you to a specific brand for reasons specific to you. Where there are two or more brands of the same drug on the Schedule, the Government subsidises each brand to the same amount - up to the cost of the lowest priced brand minus your co-payment. If you are taking a more expensive brand the price difference is paid by you at the request of the drug company and is paid to the supplier NOT to the Government. This cost is in addition to your co-payment.

At your request, the pharmacist may be able to substitute a less expensive brand where your prescriber has allowed this. If you have any concerns, you should talk to your prescriber or pharmacist. Pharmacists are legally required to charge brand premiums on behalf of the drug company concerned. The brand premium does not count towards your Safety Net threshold.

Where can I find more information?

• PBS contacts
• PBS Frequently Asked Questions
• PBS information on the Services Australia website
• PBS Safety Net information on the Services Australia website

Constraints on community pharmacies

Dispensing fees

A dispensing fee, that can form part of the total price you pay for a medication is set by the government and is adjusted on the first of July each year.

When the cost of a medicine is below the general patient co-payment the cost of your prescription may vary from one pharmacy to another as some pharmacists make additional charges above the PBS dispensing fee. However you cannot be charged more than the co-payment, except when a premium applies.

Constraints on prescribers

Treatment specification

The PBS limits the amounts of a PBS-listed medicine in a prescription and the number of repeat prescriptions before you must be re-examined by your doctor.

Restrictions on medicines

Many medications on the PBS are subsidised for a specific patient group or indication. There are three restriction categories:

• Unrestricted benefits: no restrictions apply to the therapeutic use;
• Restricted benefits: can only be prescribed for specific therapeutic uses; and
• Authority required benefits: to prescribe these, doctors need approval from Services Australia or the Department of Veterans’ Affairs. Your doctor must declare the specific conditions and circumstances that justify the use of these medicines. This is usually done by phone during the consultation or in the case of Streamlined Authority it is done electronically.

Independent Review (PBS)

Independent review is available where the Pharmaceutical Benefits Advisory Committee (PBAC) has declined to recommend the listing of a drug on the Pharmaceutical Benefits Scheme (PBS), or in certain circumstances where the PBAC has not recommended the extension of the listing of a PBS item for an additional indication.

Further information on the independent review is available on the Independent Review (PBS) pages.

Managing the cost of the scheme

Over the 10 years to 2004–05, the cost of the PBS grew by nearly 13 per cent each year. The increased cost relates to several factors, including newly-developed expensive medicines, over prescribing, an ageing population and increased patient awareness and expectations.

Spending on the PBS may reduce the cost of the wider health system by helping to prevent serious conditions developing thereby reducing hospital stays and other demands on hospitals and other health services.

Listing every medicine on the PBS would quickly make the scheme unsustainable. For example, listing a very expensive new medicine which only provides a marginal benefit over existing alternatives may not be ‘cost effective’.

Although the Government manages the price of each medicine on the PBS, the total cost of the PBS remains uncapped and therefore the overall cost of the Scheme increases as new drugs are added and as need increases. A number of strategies help ensure that the PBS remains affordable for the community while providing access to affordable necessary medicines and helping maintain a viable pharmaceutical industry. These affect all the stakeholders in the system:

• Consumers;
• Prescribers;
• Dispensers;
• Wholesalers; and
• The Pharmaceutical Industry.

Further information:

• Cost Recovery, Fees and charges - Frequently Asked Questions
• Cost Recovery Implementation Statement
• Independent review of the impact of Pharmaceutical Benefits Scheme (PBS) cost recovery November 2011 (PDF 356KB) - (Word 454KB)

Section 100 programs

Section 100 of the National Health Act provides for alternative ways of providing a medicine when the usual supply through community pharmacies is unsuitable.

The reasons are numerous and include the cost of storage, requirements for particular controls over dispensing, the need for medical supervision or administration during treatment or constraints on patient access to community pharmacies. However, these medications must still meet the criteria for listing such as clinical and cost effectiveness.

There are several programs funded under this provision including:

• The Highly Specialised Drugs Program;
• The Botulinum Toxin Program;
• The Human Growth Hormone Program;
• The IVF program;
• The Opiate Dependence Treatment Program; and
• The Special Authority Program.

What you pay for PBS medicines

To help meet the cost of the scheme, you pay a proportion (a ‘co-payment’) for your PBS medicines and the Government pays the rest of the cost. Co-payment amounts are adjusted in line with indexation on 1 January each year. Since 1 January 2016, pharmacists can discount the patient co-payment by up to a maximum of $1.00, should they choose to do so.

Indexation of the new general co-payment amount of $30.00 (introduced on 1 January 2023) will recommence on 1 January 2024.

The real cost of your medicine

The co-payment arrangements help ensure that medicines remain affordable. The full cost of your medicine can be found on pbs.gov.au by searching for the medicine and is also shown on the dispensing label.

The real cost of your medicine

The co-payment arrangements help ensure that medicines remain affordable. The full cost of your medicines is shown on pbs.gov.au by searching for the medicine and is also shown on the dispensing label.

Brand Premiums

Sometimes people have to pay more than the co-payment for prescriptions. This happens if they choose to use a particular brand of medicine listed on the PBS which costs more than another brand of the same medicine.

Generally the price of a medicine produced by different manufacturers is set at the same price. However, at the request of a manufacturer, the Government may allow an additional charge known as a Brand Premium, which is paid by the consumer. Typically this happens when a medicine comes off patent and a competing brand is listed at a reduced price. There is always a brand available without the extra cost, so you do not need to pay the brand premium if you do not want to.

Therapeutic Group Premiums

Therapeutic Group Premiums can apply to groups of drugs which have similar safety and health outcomes. Within these groups the drugs can be used interchangeably. The government subsidises all drugs within a group up to the level of the lowest price drug. Any difference between the subsidised price and the price of the drug used by the patient is called a therapeutic group premium and is paid by the patient.

There is always at least one drug within each group without a therapeutic group premium. If for a medical reason you are only able to take a drug with a premium, your doctor can request an exemption.

Special Patient Contributions Other Than Premiums

Special patient contributions can also apply because the Government and the supplier cannot agree on price. In these cases, the product is listed, but you pay more than your co-payment.

Some medicines in the same therapeutic groups may not be interchangeable because of adverse reactions, drug interactions, likely poor compliance with drug use or other reasons. When your doctor believes that there is no clinically proven alternative, the Government will pay the special patient contribution on your behalf.

Veterans and the Repatriation Pharmaceuticals Benefits Scheme

The Department of Veterans’ Affairs administers the Repatriation Pharmaceutical Benefits Scheme (RPBS) for eligible Australians.

What medicines does the government subsidise?

The Commonwealth subsidises medicines that are necessary to maintain the health of the community in a way that is cost effective.

This is achieved by carefully assessing the therapeutic benefits and costs of medicines, including comparisons with other treatments where appropriate. If a medicine is found to be acceptably cost-effective, then government negotiates its price with the supplier.

A medicine is considered cost effective by the PBAC if, for significant medical conditions, the improvements in health outcomes justify the additional costs to the Scheme (and any harms) compared with its main alternate therapy.

A number of strategies help ensure that medicines listed on the PBS provide affordable medicines for patients and an affordable scheme for taxpayers including:

• Thorough independent evaluation of evidence for clinical and cost effectiveness;
• Specifying maximum quantities and number of repeat prescriptions;
• Restricting medicines to specific therapeutic uses;
• Regularly reviewing which medicines are listed on the PBS and their prices;
• Negotiating pharmacists’ fees and allowances;
• Monitoring medicine use; and
• Educating prescribers and consumers.

An acceptably cost-effective medicine can be recommended for listing if:

• It treats or prevents significant medical conditions that are not covered, or only partially covered, by currently listed drug(s);
• It is more effective and/or less harmful than a currently listed drug; or
• It is as effective and safe as an existing listed drug.

Community need and/or benefit are also considered.

This is information about requirements when you’re paying Medicare benefits for referred or requested services. You may need more information if you’re accepting a referral or request.

What you need to know

To bill a referred or requested service to Medicare, specialist referrals or requests for diagnostic imaging and pathology services must comply with all of these:

• Health Insurance Act 1973
• Health Insurance Regulations 2018
• Health Insurance (Pathology Services Table) Regulations 2020
• Health Insurance (Diagnostic Imaging Services Table) Regulations (No. 2) 2020
• Health Insurance (General Medical Services Table) Regulations (No. 2) 2020.

Referrals for specialist treatment

Patient referrals to a specialist or consultant physician for treatment, not including general practitioners, need to meet certain conditions. The referral must include all of the following:

• relevant clinical information about the patient’s condition for investigation, opinion, treatment and management
• the date of the referral
• the signature of the referring practitioner.

Referrals don’t need to be made out to a certain specialist or consultant physician.

If you’re referring a patient, you should let them choose where to present the referral. This also applies to electronic referrals.

Single course of treatment

A referral covers a single course of treatment for the referred condition. A single course of treatment is an initial attendance at the specialist or consultant physician. It includes subsequent attendances for the continuing management until the patient is referred back to the referring practitioner.

A new referral doesn’t always mean a new course of treatment.

If a referral is for continuing management of a condition, the specialist or consultant physician must bill subsequent attendance items. However, you can bill an initial attendance item if it meets all the following:

• the referring practitioner decides the patient’s condition needs to be reviewed
• the patient is seen by the specialist or consultant physician after the expiry of the last referral
• the patient was last seen by the specialist or consultant physician more than 9 months earlier.

If the patient has a new or unrelated condition, the specialist can start a new course of treatment if there is a new referral in place.

Referral periods from a GP to a specialist

A referral from a general practitioner (GP) to a specialist lasts 12 months, unless noted otherwise. The referral starts from the date the specialist first meets the patient, not the date issued.

If a patient needs continuing care, GPs can write a referral beyond 12 months or for an indefinite period.

If a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition.

Referral periods from a specialist to another specialist

Referrals from specialists and other consultant physicians are valid for 3 months unless it's for an admitted patient.

Referrals for admitted patients are valid for 3 months or the duration of admission, whichever is longer.

Lost, stolen or destroyed referrals

A written referral that is lost, stolen or destroyed is valid for only one attendance by the patient. You must get a valid referral before you can bill any subsequent services. The account, receipt or assignment form must include all of the following:

• the referring medical provider’s name
• practice address or provider number of the referring medical provider (if known)
• the words ‘lost referral’.

Referrals for allied health services

You can refer patients for allied health services under the following initiatives:

• Chronic Disease Management
• Better Access to psychiatrists, psychologists and general practitioners
• Better Start for Children with Disability
• Eating disorder treatment and management
• Helping Children with Autism program
• follow-up services after Aboriginal and Torres Strait Islander health assessments.

Requests for diagnostic imaging services

Requests for diagnostic imaging services must have:

• the requesting practitioner’s full name, provider number or practice address
• the date of the request
• a description of the services requested.

Patients can choose a health professional and don’t need to give a request to a specific practice. This also applies to electronic requests.

Requests for pathology services

Requests for pathology services must have all of the following:

• the patient’s name and address
• the patient’s hospital status
• the requesting practitioner’s full name, provider number and practice address
• a description of the services requested
• the date of the request.

Patients can choose a health professional if there’s no clinical need for a specific pathologist to do the service. This also applies to electronic requests.

Electronic referrals and requests

You must comply with the Electronic Transactions Act 1999 when sending referrals and requests electronically between third parties. Section 10 has more information about electronic signatures.

You must save, store and retain access to electronic referrals or requests so you can retrieve them unaltered. Your records may need to be checked in the event of an audit.

Department of Health. (n.d.). CMP Guide to Invoicing.

CMP Guide to Invoicing

This invoicing guide details the requirements for submitting a tax compliant invoice, as set by the Australian Taxation Office and detailed in the Medical Services Agreement (MSA) between the Health Service Provider (HSP) and the Contracted Medical Practitioner (CMP).

The Western Australian Government Medical Services Schedules Policy (WAGMSS) defines the eligible medical services, item numbers and fees payable that CMPs may invoice. WAGMSS is updated each year effective 1 December.

The current WAGMSS Administration Instructions and Procedures, along with the current Schedule of Fees, can be accessed from the Contracted Medical Practitioner page of the Department of Health public website at www.health.wa.gov.au.

Mandatory Information

The following information must be included on every invoice.

1. The invoice must clearly state:
   • The words Tax Invoice
   • Your Trading Name
   • Your Trading Address
2. Australian Business Number (ABN)
   • If you do not have an ABN, contact MAAS Support on MAAS_Support@health.wa.gov.au
3. Invoice Number and Invoice Date
   • The Invoice Number must not exceed 50 characters
   • The Invoice Number can only include alpha numeric characters plus the following special characters: * - / _
   • One invoice (only) per file in PDF format is preferred
4. CMP Provider Number (for the purposes of invoicing on a Fee for Service basis)
   • Your CMP Provider Number consists of your MPO number, site code and contract number. For example, 500000-BY1-1
   • Your CMP Provider Number is specific to the hospital referenced in your MSA
   • If you have more than one MSA, you will have more than one CMP Provider Number
   • A tax compliant invoice must include the CMP Provider Number applicable to the hospital where the medical services were provided
   • Separate invoices must be supplied for each CMP Provider Number
5. Date the relevant service was provided
   • The date cited on the invoice will be verified against the hospital’s records
6. Item number for the relevant service
   • Each service that is invoiced must include the correct item number from the Western Australian Government Medical Services Schedules Policy (WAGMSS) and the correct applicable fee from the WAGMSS Fee Schedule
7. Patient Details
   • The Unique Medical Record Number(UMRN) is assigned to the patient by the hospital. The UMRN as well as the patient’s name and date of birth should be referenced in the invoice
   • If a patient is attended multiple times on the same or on different invoices, you must state the times of each attendance and state why multiple attendances were required
   • Invoices may include items for more than one patient
8. Any applicable service qualifiers (item description)
   • Each service item must include a description of the service
   • If the same item number is claimed on the same day (this only applies for surgical items) for the same patient more than once, the description must include the body position of the service
   • Service qualifiers are factors stipulated in the WAGMSS that affect the agreed fee for a given service
   • Service qualifiers include:
     • Where the service was provided more than once on the same day, the number of occasions and the time each service was provided
     • Where the service was provided after hours, or if it is an emergency procedure, the time the service was provided
     • Where the service was surgical assistance, the base item and which doctor they assisted
     • Where travel costs are claimed, the number of kilometres travelled
9. The Health Service Provider name
   • Invoices must show which Health Service Provider is being invoiced, e.g. WA Country Health Service; East Metropolitan Health Service etc, and the hospital name
   • In the case of an anaesthetist, the account should also show the name of the Medical Practitioner who performed the operation
10. Agreed fee, exclusive of GST, for the relevant service
    • The fee must be sourced for the relevant service item from the current WAGMSS Fee Schedule
    • Invoices with fees that do not match the current WAGMSS fee for the relevant service item will be rejected and returned to the CMP to correct. There is a $2 over and $10 under tolerance built into the system
    • WAGMSS is updated on 1 December each year and the updated fee must be applied to invoices for services provided on and after that date
11. GST payable
    • The GST payable must be specified
12. Payment instructions
    • Payments of invoices are made to the bank account nominated by you on your Application for a CMP Registration Number
    • Although not mandatory, it is preferable that you include payment instructions on your invoice
    • If you wish to update your payment details, you should contact MAAS Support via MAAS_Support@health.wa.gov.au

Additional Mandatory Information for Anaesthetic Invoices

Invoices for Relative Value Guide (RVG) anaesthetic procedures must include three components from the WAGMSS Anaesthetic Items Fee Schedule.

Together, these components give the total RVG derived value for that service:

• The Base RVG Units that relate to the procedure item number
• The start and end times (in a 24 hour clock) of the procedure and the corresponding Time Units
• The Modifying Units that relate to the physical status and other factors that relate to the patient
• In addition, the invoice must specify any applicable afterhours loading (EAHA).

NSW Government. (n.d.). Invoicing information for NSW Health doctors.

A new compulsory third party (CTP) Green Slip scheme started on 1 December 2017. The scheme focuses on early support and recovery, to better support people injured in NSW motor accidents.

This information:

• explains how to invoice patients who have been injured on NSW roads
• is provided by the State Insurance Regulatory Authority (SIRA) in consultation with NSW Health, the Australian Medical Association - NSW( AMA) and the Australian Salaried Medical Officers’ Federation of NSW
• applies to admitted and non-admitted patients who are injured in NSW motor accidents on or after 1 December 2017.

What does the 2017 scheme mean for public hospital patients?

Almost all people injured in motor accidents in NSW can receive statutory benefits (including for reasonable and necessary treatment and care) for the first 52 weeks from the date of the motor accident, regardless of fault. Payment of treatment and care benefits may continue beyond 52 weeks for as long as needed if the patient was not at fault for the accident, has injuries which are not assessed as ‘threshold injuries’, or if they were 16 or under at the time of the accident.

A purchasing agreement between SIRA and NSW Health covers almost all people injured in motor accidents in NSW, regardless of fault and whether they make a CTP claim or not, for:¹

• Emergency Department care
• acute inpatient services
• subacute and other non-acute inpatient services
• mental health services
• non-inpatient care and other ambulatory care services
• ambulance transport services (other than between Local Health Districts).

The purchasing agreement enables doctors to exercise their rights of private practice.

Important information if your patient is a CTP claimant

Time to lodge a claim

The patient has three months from the time of the accident to lodge a claim.² If the patient wants to also claim for ‘back pay’ for lost earnings from the date of the accident they must lodge the claim within 28 days of the date of the accident.

Reasonable and necessary care

Under the Motor Accident Injuries Act 2017, the CTP insurer is obliged to pay for treatment and care (including rehabilitation) that is ‘reasonable and necessary’ on an accepted claim. What is ‘reasonable and necessary’ in one case may not be reasonable and necessary in another.

Insurers need relevant medical information and time to make decisions about what is reasonable and necessary, including for transfers to rehabilitation or other facilities. Insurers may therefore request clinical notes and other relevant medical information.

For transfers, the patient may also need written medical clearance from a doctor for partial weight bearing in order to participate in rehabilitation.

Insurers are required to advise the claimant and health service provider in writing of a decision regarding treatment and care (including transfers) as soon as possible but within 10 calendar days of receipt of a request, and if approved, state the costs the insurer has agreed to meet.

Payment of invoices by insurers

Insurers are required to pay accounts as soon as possible but within 20 calendar days of receipt of an invoice.

Disagreements with an insurer decision

If you, as a treating doctor, disagree with an insurer’s decision, discuss it with the insurer claims officer or rehabilitation advisor. If the situation remains unresolved, you can ask the insurer to escalate the issue as a complaint.

Your patient can also ask the insurer to conduct an internal review of the decision and use SIRA’s Dispute Resolution Service to further escalate disputes with insurers if needed.

How to invoice a patient injured in a motor accident

Documentation of professional attendances should be in accordance with advice provided in the most current Medicare Benefits Schedule.

Patient CTP claim status	Billing Information
Patient has made a CTP claim and knows their claim number	Bill the CTP insurer directly, using AMA rates, including: claim number relevant AMA item number/s patient’s name date of accident your ABN (not applicable to staff specialists), address and GST (if applicable).
Patient has made a CTP claim but does not know their claim number or Patient intends to make a CTP claim	Bill the patient, include the information above (as for those who know their claim number) and add clear instructions to the patient to forward the invoice to the insurer. To confirm if the patient has made a claim, or if not, whether they intend to make a claim, revenue staff at the facility/LHD should attempt to contact the patient or family members prior to discharge or a minimum of two weeks after admission. If required, they should attempt to make further contact 28 days after the admission date. Any change in financial classification should be communicated to the treating physician/s. If the rooms of a Visiting Medical Officer (VMO) are advised that the patient does not intend to claim, practice staff should inform the relevant staff at the facility/LHD to ensure correct classification of the patient occurs.
Patient has stated they do not intend to make a CTP claim	A senior revenue officer at the facility/LHD will change the financial classification to one of the No Claim options. VMOs will have the option to submit a claim through the normal claiming processes for treating public patients (or to a private health insurer or the Department of Veterans’ Affairs, should they accept the claim).
Patient is not a compensable patient (for example, charged with serious driving offence or knowingly drove an uninsured vehicle)	In the event of the hospital becoming aware that the patient is not compensable, a senior revenue officer will reclassify the patient to an appropriate financial classification. If the patient is still admitted they may elect to be either a public or private patient in a public hospital. If the VMO’s rooms become aware that the patient is not eligible, practice staff should inform the hospital so a valid election can be made and the patient reclassified.

Resources for you and your patient

For you

Treatment guidelines and information for health professionals.

Insurers’ responsibilities for treatment and care: Part 4 of the Motor Accident Guidelines.

Working in the CTP scheme.

Threshold injury: information for General Practitioners (GPs) in the NSW CTP scheme.

For your patient

Guide for people injured on NSW roads

Recovery advice for injured people

Understanding threshold injury.

Department of Health and Aged Care. (2023, January 1). About the PBS.

Follow up on unpaid invoices

As a healthcare practitioner, it's ideal to always be paid for your service at the time of the appointment. In real life, this may not always happen. With Halaxy, you can automatically email invoices on their due date, along with a secure link for recipients to instantly send payments. You can also create campaigns to send follow up emails or SMS for unpaid invoices past their due date.

These features are completely automated, providing you with a hands-free experience for chasing up late payments and giving you more time to treat your patients.

Automatically email invoices on the due date

1. Create an email communication template advising patients that their invoice is due. Use the dynamic terms [Invoice Due Date] and [Payment Link], which will automatically populate the email with the invoice due date and the secure link for recipients to pay.
   
2. Click Settings > Payments.
3. Under the section Invoice Due Date, click the Edit icon for the level you wish to edit or click Add New to create a new due date setting.
   
4. In the pop-up, for the level you’ve selected, set your invoice due date and configure the following:
   • Email on Due Date: Select Automatic.
   • Payer: Tick the checkboxes to select if you wish to automatically email invoices to patients or organisations or both.
   • Select any fees to be excluded: Invoices with any of the fees you select in this field will not be sent automatic invoice emails.
   • Email Template: Select the email communication template you created in Step 1.
5. Click Save.

If invoices are due on the same day they are issued (you have set invoices to be due 0 days after the invoice date), please allow a few hours following the appointment for the invoice to be emailed.

Run a campaign for overdue invoices

You can also run an unpaid invoices report and create a campaign to automatically send follow up emails or SMS (even at a regular frequency) to all those with unpaid invoices past their due date.

1. Create an email communication template advising patients that their invoice is overdue. Use the dynamic terms [Invoice Due Date], which will automatically populate the email with the invoice due date.
   
2. Click Reports > Finance. At the top-right, click New Report.
3. In this screen, set the following:
   • Report Type: Select Unpaid Invoices.
   • Overdue: Select Overdue. (Optional: Select how many days overdue you would like to filter for. Leave blank to include all overdue invoices.)
4. Click Run.
5. The report appears showing overdue invoices. At the bottom of the page, click Save.
6. Give your report a name and description. Click Save.
7. On the top-right, click Set as Campaign.
   
8. Choose your campaign parameters and select the communication template you created in Step 1. (Optional: Set the campaign to repeat each week.)
9. Click Save.

From here, all patients with an overdue invoice will be sent the communication template you selected.