By Kirsty Machon
Members are advised to exercise caution or contact Optometry Australia for assistance if they are uncertain about their legal responsibilities in relation to health fund claiming through the HICAPS or CSC/iSoft claims systems.
Optometry Australia continues to work with health funds to achieve clarity and consistency, but reminds members using HICAPS and CSC/iSoft that they are subject to provider agreements that state that for a claim to be made, the stated services and products must have been provided to that member.
Towards the end of the year, it is common for patients to want to claim for optical appliances at the time of ordering, because they want to use remaining annual optical benefits before expiration of the year’s policy on 31 December.
Patients acting late in the year to use their optical benefits can be caught by this requirement if the optical appliances cannot be completed for collection in time.
Some health funds, HCF in particular, are unambiguously advising that using the HICAPS or CSC/iSoft claims terminals means claims can be submitted only when spectacles have been completed and collected. Optometry Australia has had this advice confirmed by HICAPS staff.
There is a lack of consistency among health funds on this issue, according to anecdotal member reports and information made available to Optometry Australia.
Optometry Australia says that according to advice from HCF, claims for optical appliances not processed through the HICAPS or HealthPoint electronic claims systems may be able to be paid by the fund even if a fund member has not collected the completed product.
This is because such claims do not fall under legal agreements that apply to transactions undertaken through HICAPS and CSC/iSoft, which require that services have been provided to the patient at the time the benefit is claimed, and require the fund member to declare that they have received the products and services listed on the claim on that specified date.
Optometry Australia’s advice is that optometrists need to consider and act on their own legal obligations if a patient is requesting a claim be put through when the product is not yet delivered.
Optometry Australia CEO Genevieve Quilty says she is aware of members’ frustration about this issue, which arises annually.
‘We are talking to the health funds about it,’ Ms Quilty said. ‘For example, the HICAPS and CSC/iSoft agreements are understandably set up to ensure patients receive the services they are claiming.
‘However, the retail aspect of optometry, where there may be a delay between payment or deposit and collection, might mean there is room for further discussion about the best way to meet the needs of fund members without disadvantaging service providers.’
If a member, even at their own request, signs to say they have collected goods when they have not, it may be considered that the HICAPS or HealthPoint provider has effectively asked that patient to make a false declaration, breaching the agreement.
Optometrists risk being suspended as providers by the health fund if this occurs.
Medibank Private has conducted compliance audits, resulting in some optometrists being suspended due to non-compliance with fund rules.