When using health fund gapcover arrangements, claims may be made as either no-gap or known-gap. Known-gap funds allow a separate copayment to be charged to the patient. These are

 

Medibank Private - maximum gap of $500 per claim per doctor (from 1 June 2010)

 

AHSA funds - up to $500 per claim, from July 2020. (Prior to this, up to $400 per item, provided this is not more than the AMA fee for that item.)

 

BUPA - maximum gap of $500 per claim (from 1 July 2014)

 

HCF - maximum gap of $500 per claim per doctor (from 1 July 2015)

 

St Lukes - 10% above the StLukes gapcover fee.

 

HBF - 10% above the HBF gapcover fee. HBF has several schedules, see here for details.

 

Other funds, e.g. NIB operate on a no-gap basis and do not allow patient copayments when using their gap cover schedule of fees. If you want to charge more than the funds' gap cover amount, send the account to the patient, who will receive rebates up to the Medicare schedule fee only.

 

For a fund that does not allow co-payments, if you want to charge the gap-cover amount, then you can't charge anything extra. If you want to charge e.g. $800 and this is above the gap-cover amount, you need to set this as the MyOwn fee and send the account to the patient. In this case, the patient will receive rebates from Medicare and the fund that come up to the Medicare schedule fee only, and any remainder will need to be paid by the patient. This may have the patient paying more than anticipated. To minimise the patient's gap, either charge the gap-cover fee only (patient pays nothing), or reduce the total fee (reduces patient gap, but also reduces dr's income).

 

For funds that do allow copayments, proceed as follows.  To charge a total fee of e.g. $450, the best method is to create a MyOwn fee, spreading the $450 total across all items. You should also calculate the fund fee which will appear in the fund fee column. Then on the Fee page, select the fund fee, then click the small <D> button which will insert the 'D'ifference (between the MyOwn fee and the fund fee) into the copayment field. You can then send the standard account to the fund, and the copayment account to the patient.

 

In July 2015 there were a number of changes made to the copayment management methods in AA, particularly for HCF - full details are given here.