Dr Craig Lilienthal GP and medicolegal adviser in Sydney , NSW .

How do specialists get away with recharging patients ?

AM very embarrassed — nay ,

pissed off — when I hear that some of the specialists to whom I refer patients often charge initial consultation fees when following up patients for established conditions .

The specialists do this when the patient ’ s referral has just been renewed and / or they haven ’ t seen them in the previous 12 months .

To those of us at the bottom of the food chain , this seems like a rip-off . There are no special initial consultation item numbers or fees for us !

As I see it , the main purpose of

referrals is to ensure that patients really do need to see non-GP specialists , that they are referred to the appropriate specialists and that the specialists report back to the referring GPs in a timely and meaningful way .

We are supposed to be the gatekeepers for appropriate and quality medicine .

Referrals between GPs and specialists are valid for 12 months , and referrals between specialists are valid for three months .

This longstanding agreement is to make sure patients are not lost to their GPs and that GPs are kept up to date with their welfare .

After all , we are involved in our patients ’ day-to-day care , and we can ’ t do this properly if we don ’ t know what the specialists have done or are doing to our patients . But what does Medicare say ? Believe it or not , Medicare allows specialists to re-charge for an initial attendance under very generous conditions , including “ the patient is seen by the specialist or consultant physician after the expiry of the last referral ”. 1

Of course , Medicare is totally silent

about initial consultations for GPs . We provide ongoing care only .

I hate indefinite referrals because they often herald a breakdown in communication between GPs and specialists .

It ’ s bad enough when a patient comes back to us before we receive the hospital ’ s discharge summary ; it ’ s even more galling when private consultants don ’ t keep us up to date with

our shared patients ’ conditions .

Specialists ’ reception staff often

ask for indefinite referrals because it saves them the trouble of having to chase up patients for new referrals every 12 months .

But do indefinite referrals moderate the impulse to re-charge for initial consultations ?

The fact that the Medicare rules require new referrals every 12 months is not an excuse for specialists to reset their cash registers and charge for initial consultations for the follow-up

of ongoing conditions that they have already diagnosed and are already managing . Cha-ching ! No problem for new conditions but existing ones ?

Okay , there are some conditions for which we can see the need to provide indefinite referrals , but these are usually for oncological services or palliative care , where there is little further that we GPs can help with when dealing with the primary condition .

The fact that new referrals are required every 12 months is not an excuse for specialists to reset their cash registers .

But we are often responsible for the day-to-day care of these patients and their families . To do this properly , we need feedback from the specialists and their teams . So , what can we GPs do about it ? Well , we could :

1 . Stop referring patients to specialists who do this money-spinning trick — maybe .

2 . Speak to the specialists and ask them to justify this money-spinning trick — oh yeah .

3 . Advise the patient to challenge

their specialist ’ s fees in these situations — as if they could .

4 . Ask the AMA and the specialist colleges to address this with their members — as if they would . 5 . Bury our heads in the sand and pretend it is not our problem — most likely . Pretty gutless , aren ’ t we ? There is also the problem of who is to follow up our patients . Medicolegally , the specialists / attending doctors are responsible for removing the stitches , postoperative wound care , assessing the histopathology , ongoing medications and follow-up appointments .

Most specialists do this , but many don ’ t , and some even tell their patients to see their GPs to do these tasks — most of which are covered in the cost of the procedure and subsequent care .

Clearly , this goes beyond the concept of shared care and looks very much like specialists dumping the mundane stuff onto us lowly paid and overworked shitkickers .

Sadly , see the above list again , take a deep breath and count to 10 . Reference 1 . Medicare : bit . ly / 3JWW9AJ