Health Fund Rebates and Split Fees



ANTA has recently had a notification from a member where a Health Fund flagged the practitioner for split fees and was requesting the practitioner to refund all accumulated benefits issued to clients as a result of the spit fee payment.

The Situation:

The practitioner has qualifications in two separate modalities, both recognised by health funds and able to issue rebates. The practitioner completed genuine consultations for one client in both modalities, back-to-back, booked separately, consulted separately, and billed separately. The practitioner also genuinely believed they were abiding by the terms and conditions set by health funds, even after consultation with a call centre operator from a major fund had verbally approved this.

The Response from the Fund:

The Fund does not exclude a provider from charging for two treatments (split fees), but the terms and conditions state that the Fund will only pay benefits on one consultation, per patient, per practitioner, per day.

E3 General Treatment

E.3.1 When Benefits are payable

  1. Benefits will only be payable in respect of charges made for services rendered by General Treatment providers who are Recognised Providers or who are members of organisations who are Recognised Associations and satisfy the requirement of the Private Health Insurance (Accreditation) Rules.
  2. The Company may at its discretion require a General Treatment provider to complete a declaration concerning his, her or its Private Practice status, in the form prescribed by the Company from time to time, prior to payment of Benefits.
  3. Benefits for General Treatment Consulations will only be payable on the basis of one consultation per patient, per practitioner, per day.
  4. Benefits for General Treatment consultations will only be payable as described in the Schedules and only for the time during which a Member is receiving direct or active attention. It does not include preliminary or subsequent attendances such as making of appointments and writing reports and these cannot be treated as separate consultations.
  5. The Benefits payable and the conditions associated for General Treatment services by Recognised Providers are listed within the relevant Product Schedules. These Fund Rules are supported by the Ancillary Schedules and Dental Schedules as maintained by the Fund.


The Result:

In this instance, ANTA was able to liaise with the Fund on behalf of the practitioner to obtain a clear definition of the terms and conditions of the Fund to provide to the practitioner. The Fund has generously revoked their requirement for the practitioner to return rebates obtained in conflict with the funds' conditions.

ANTA has agreed to communicating this with members for better awareness of the terms and conditions set by private health funds, and all practitioners MUST adhere with these conditions. ANTA will not be able to achieve the same result in another case of this type as members have been advised of the terms of preventing split fee rebates. This applies to all health funds and should be taken seriously.




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