BUPA medical billing changes effective 1 August 2018

You have likely heard that BUPA made some changes to their Medical Providers Gap Schemes, which came into effect on the 1st August. We would like to take this opportunity to give you our quick guide as to how this might impact your billing.

1. 1. 1. Billing private patients in a public hospital
         There are two ways BUPA will now reimburse you;

1. 1. 1. 1. For pre-booked admissions, you can charge either No Gap or Known Gap rates. BUPA will determine whether an admission is ‘pre-booked’ based on receiving an electronic cover check from the hospital at least 2 days prior to the patient’s admission;
         2. For admissions via the emergency department or admissions without the electronic cover check 2 days prior, BUPA will only pay No Gap rates. This means that you will need to check whether the hospital has performed the cover checks 2 days prior to an admission before choosing to bill Known Gap rates (i.e. with an out of pocket amount for the patient). In other circumstances, BUPA will now only pay No Gap rates. You also retain the right to charge patients a private fee of your choosing and can choose not to engage with either the No Gap or Known Gap schemes of BUPA. We recommend that you have robust IFC procedures in place if you plan to pursue this option.
      2. Billing private patients in a private hospital which has an agreement with BUPA;
         Nothing changes for these patients – you can continue to bill these as you have previously;
      3. Billing private patients in a private hospital which does not have an agreement with BUPA (including second tier hospitals);
         BUPA will now only pay up to 100% of the MBS fee. No Known or No Gap claims will be reimbursed for services you undertake at these facilities. This means you will need to know if a facility has an agreement with BUPA in order to be able to bill using those schemes. You can find out by asking the hospital, or we have attached a list of the facilities which currently have an agreement with BUPA. As is always the case, you still retain the right to charge patients a private fee of your choosing. However your patients will now pay a higher out of pocket amount at these facilities because BUPA has reduced its benefits, including for patients with full private cover. We recommend that you have robust IFC procedures in place if you plan to pursue this option.