Articles and Case Studies

Working After Hours

27 Aug 2018

GPs working for an after-hours doctor service experience all the usual medico-legal issues which arise in general practice, plus some additional issues specific to treating patients out of hours.

Medicare billing

If you regularly bill MBS Items 597-600,you may have received a letter from Medicare last year asking you to review your billing to ensure compliance with the MBS descriptors.

One issue requiring clarification was whether the “urgency” of these MBS Items is assessed prospectively or retrospectively. Our understanding (based on Medicare advice at the time) was that the urgency should be assessed prospectively, i.e. based on the patient’s assessment of urgency, not your retrospective assessment after the event.

Note that as of 1 March 2018, Medicare have released additional guidelines and new item numbers. Urgency is now (still prospectively) assessed on a requirement that ‘urgent assessment’ is required, not ‘urgent treatment’. “Doctors will be able to claim the items if they consider it clinically relevant that the patient requires urgent assessment in the after-hours period”. The guidelines detail minimum triaging standards “to better identify patients in need of urgent afterhours services and those who could reasonably wait until the next in-hours consultation period”. Doctors should also ensure that their notes provide some indication as to why urgent out of hours assessment was required (particularly if it is later apparent at the time of consultation that the condition did not require urgent assessment).

The Medicare letter was a wake-up call to doctors routinely billing urgent items when an urgent visit is not indicated. The guidance provided on prospective assessment does not give doctors carte blanche to bill urgent items when there was no indication the consultation was urgent. You are responsible for your billings, not the after-hours service, so you should know what is being billed to your provider number.

It’s also worth noting that the urgent attendance after-hours item numbers only allow attendance on “not more than one patient on the one occasion”. 

Chaperone issues

In the event an intimate examination is clinically indicated during an after-hours visit, we suggest you seek written consent from  the patient, including confirmation that the  patient has been offered a chaperone and declined, or the name (and relationship to the patient) of a support person present during the examination. You should consider having a pre prepared consent form or an addendum to the after-hours consent papers.

Phone triage

All services should have a triage policy which is suitable for a range of staff, from reception staff through to medical practitioners. The policy should address a variety of scenarios such as:

  • patients calling from outside the callout range
  • urgent calls that require an ambulance
  • semi-urgent calls that require a doctor to call back immediately
  • standard after-hours calls
  • non-urgent calls, where the patient may be advised to see their own GP the following day.

If a patient requests an ambulance and is not capable of making the call, ensure patient consent is obtained and documented.

If the patient terminates the call to ring an ambulance, request a call back once the ambulance has been called, and document the callout.

If a patient refuses an ambulance, and opts for an alternate form of transport, make sure this is clearly documented in the notes.

Treatment refusal

Provided a patient has capacity to make health decisions, the patient can refuse treatment against medical advice. If this happens, you should:

  • reinforce the reasons why you are recommending treatment
  • engage with a friend or family member, with the patient’s consent
  • advise the patient, friend or family member about signs of deterioration and where to seek further medical advice
  • ask the patient to sign a “refusal of treatment” form and/or document the refusal clearly in the notes
  • inform the patient’s usual doctor of your visit and the treatment refusal.

Reference


  1.  MBS Online: Medical Benefits Schedule. 
Employment Essentials, General Practice
 

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