Trying to understand Medicare #1

Referrals to Specialists

In Australia you don’t need a Referral to see a Specialist. So, say you wanted to see a Plastic Surgeon about a skin lesion, you can just find a Plastic Surgeon on the internet or ask a friend and make an appointment and off you go. But be prepared for a bill – sometimes a really big bill. This is because, you won’t be able to access a Medicare rebate for the Plastic Surgeon’s fees. To do so you need to first have a valid referral from your GP. But it is not as simple as just calling your GP and asking for a referral.

What is a Referral letter?

It is a legal requirement to have a valid referral to access Medicare for the care provided by the Specialist. In Medicare speak, the referrer must first “consider the need for the referral.”

A referral is a written, signed and dated request to a Specialist to assist with care of your medical problem. Often the Referral is to a specific Specialist, but this is not necessary. From DHS

“Referring practitioners don’t need to address a referral to a specific specialist or consultant physician. Patients should also be given the choice of where to present the referral, including where the referral is submitted electronically.”

This however can be an issue for referrals to public hospitals (that is a story for another time).

In the Referral letter, I usually would explain the problem, what I would like the specialist to do and provide a list of your medications, allergies, previous medical problems along with a copy of relevant investigations that may have been done. I find that this is best done face to face in a consultation to avoid miscommunication.

A specialist may run a triage system; a way of sifting through referrals to pick those that need more urgent care.

There is an expectation that a letter of reply will be forthcoming following your consultation with the Specialist.

How long does a Referral last?

A standard Referral is for 12 months of care. This starts when you first see the Specialist, not form the date the Referral was made. This makes sense as you are unlikely to see a Specialist on the same day as seeing the GP.

Referrals can be made for an indefinite period. but this is generally used for conditions that are unlikely to go away. For example, you could be referred to an Endocrinologist for help with managing diabetes indefinitely.

What is a Referral for?

A referral is for a single course of treatment of the specified problem. If a new problem arises then a new referral is needed. Therefore, if you see an Orthopedic Surgeon to manage your broken arm you will need a new referral to deal with your hip replacement.

The Specialist can bill more for a for a first visit, then less for subsequent. Unless a new problem arises, which requires a new referral, you shouldn’t be billed for a new visit after that.

Who does Referrals?

GP can refer to all Specialists.

Opticians can refer to Ophthalmologists. Midwives and Nurse Practitioners are also able to make Referrals under Medicare rules. Dentists can refer to Dental or Orofacial Maxillary Surgeons.

A Specialists can refer to another Specialist but these referrals only last 3 months. An example here could be a Paediatrician may refer to a Paediatric Neurologist to help with management of problematic epilepsy. For ongoing care by the second Specialist a GP’s referral may be needed.

Backdating Referrals

As a Referral is a legal document, Medicare does not permit backdating a Referral.

A Specialist can see a patient without a valid referral only in an emergency. Apparently, if your dog ate your referral, or another good excuse, there is a exemption available for you to claim your rebate if the Specialist notes that the “Referral is lost”. I am sure that Medicare would get suspicious if this happened a lot. Medicare do audit what GP’s and Specialists get up to make sure the rules are being followed. There are fines for not following the rules!

If you need a Referral make sure you see your GP before seeing the Specialist if you wish to get a Medicare rebate for the service. Asking your GP for a backdated Referral is like asking the Specialist to forward date your consultation so you can get a Referral. Both are not permitted under Medicare.

One final thought

Surprisingly, your may find that your GP may actually be able to fix the problem you want a Referral for and save the inconvenience of seeing a Specialist.

Medicare rule can be found here

Here is a summary from the AMA

For more details you may wish to read the Health Insurance Act 1973 and Health Insurance Registration 1975 but it isn’t easy reading with its subsections and subregulations, respects and accordances. Lots of Legal speak.



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