On a patient's account, AA stated that the HCF benefit would be $174.10. However, HCF paid $217.55. Why?

 

This is an idiosyncrasy with HCF where they will rebate up to their no-gaps rate, if the charge for any item is less than the no gaps rate, even if you are not using a no-gap system. Consider the following example, where the Medicare schedule fee is $696.40 and the patient has been charged a MyOwn fee of $1400.00.

 

 

 

 

The schedule fee is 696.40, the Medicare 75% rebate is 522.30, and the correct fund 25% rebate is 174.10. If you charge above the schedule fee, and don’t use the no-gaps system, all funds will rebate 25%.

 

However, HCF will rebate up to their no-gaps rate, if the charge for any item is less than the no gaps rate, even if you are not using a no-gap system.

 

In this example, using a MyOwn fee of $1400, the fee for 17610 is 86.45 (if the total is spread evenly over the items). HCF have probably calculated it this way too, and since 86.45 is less than the HCF no-gaps fee of 95.00, they have paid 86.45 for this item. The difference between 86.45 and the schedule fee for 17610 (43.00) is 43.45. This is exactly the amount that the patient’s rebate differs from the rebate that AA calculates (and that every other fund pays), that is 174.10 + 43.45 = 217.55.

 

The problem only seems to occur with 17610, because the no-gaps rate is so much higher for this item than for any other. It is 121% of the MBS fee, where other items are typically 20-60% higher. This makes it more likely that a standard MyOwn fee will assign an amount to this item that is lower that the no-gaps rate.

 

AA can’t calculate this adjustment. Also, since it only relates to HCF, and usually only with item 17610, and it could be changed at any time without notice, we’re unlikely to build this into the system.