Referrals 101

Maintain an up-to-date list of specialists, including subspecialties and special interests.
Use trusted resources:
- HealthPathways via your PHN
- Specialty directories from colleges or societies
- Peer recommendations
Consider patient preferences, including:
- Location and access
- Cost (bulk billing vs. private)
- Cultural fit, language needs, or prior experiences

Both are valid under Medicare rules.
Named referral:
- Use when referring to a specific doctor
- Required for some public hospital outpatient clinics, especially when:
  - The specialist operates under a Right of Private Practice (RoPP) and bills Medicare.
  - The hospital requires a specific name to facilitate triage or MBS billing.
Open referral:
- Addressed to a specialty or clinic (e.g., “Dear Cardiologist”)
- Offers greater flexibility in triaging to the most appropriate clinician
Referrals may be declined if a practice or hospital cannot accept them (e.g., mismatched subspecialty, inappropriate clinic).

Tailor the letter to the receiving clinician and include:

Presenting issue and clinical question
Current medications, allergies, comorbidities
Relevant history: family, psychosocial, occupational
Exclude irrelevant sensitive information
Use RACGP-recommended structures and ensure it is individualised
In specialist-to-specialist referrals, CC the patient’s regular GP if not the original referrer

Permissible under Medicare if:
- Sent via secure channels
- Includes electronic signature and timestamp
Accepted secure methods:
- Secure messaging platforms
- Password-protected/encrypted emails
Ensure:
- Correct recipient
- Safe handling (delete from sent folder)
- Staff trained in IT security
Format:
“Electronically signed by Dr [Full Name], [Provider Number]”

You must use your own provider number for referrals and MBS items.
Each practice location requires a distinct provider number.
If you leave a practice and close the number before the patient sees the specialist, their Medicare claim may be rejected.

To be Medicare-eligible, a referral must include:

GP to specialist:
- Standard: 12 months (from date of first consult)
- Can be indefinite if for ongoing care –
  - An indefinite referral is one that allows a specialist to continue managing a patient without needing renewal of the referral each 12 months.
  - For a chronic or ongoing condition requiring long-term specialist care.
  - Medicare allows GPs to write an indefinite referral if they document that it is clinically appropriate.
  - How to Write It
    - Must clearly state:
      “Indefinite referral for management of [condition]” or
      “This is an indefinite referral”
  - A new referral is still needed if:
    - The patient develops a new or unrelated condition
    - They need to see a different specialist
    - Not valid for specialist-to-specialist referrals (these are always 3 months maximum)
    - New referral needed for new/unrelated condition
Specialist to specialist:
- Valid for 3 months only

If the referral is for a clinically significant condition, the GP must initiate a follow-up system:
- Use practice software recalls or tasks
- If not available, use manual systems (e.g., spreadsheets or notes)
Note: GPs are not legally obliged to advocate for quicker appointments — but are responsible for clinical follow-up

Some public outpatient clinics require named referrals to enable specialists to bill Medicare under RoPP.
These arrangements are:
- Legal and structured
- Regulated under the National Health Reform Agreement
- Often require informed financial consent
Not double dipping if:
- The MBS is not billed in addition to public hospital funding for the same service
- The arrangement is transparent and declared
Unlawful double-claiming occurs when both public funds and Medicare are claimed for the same service without proper structure

Expect: