Professional Services: Sticky issues for VMOs

Ever been left scratching your head wondering why a V-Money claim was rejected? Lately, we’ve been talking to a lot of VMOs about their experiences with the V-Money system, and helping them work through some of its hidden tricks and traps. In the process, we came across one particularly sticky issue which isn’t to do with V-Money, but which has led to a number of VMOs missing out on V-Money payments. More significantly, it may also have left unwitting VMOs exposed to potential medico-legal and professional liability for procedures they didn’t perform, on patients they didn’t believe were under their care!

The issue

How would you feel if your V-Money claim was rejected because a patient you believed was public had subsequently been reclassified as private? In theory, this should never happen as the rules under the National Standards for Admitted Patient Election Processes seem quite clear:

• patients are to be classified and treated as public until a valid election is made for private treatment,
• once made, elections can only be altered in the limited ranges of “unforeseen circumstances” and
• even if unforeseen circumstances do arise, any consequential change in the election only applies from the date of the change (ie, it isn’t applied retrospectively or “backdated” to the date of admission).

However, where the patient defers their election and subsequently changes that election, some hospitals are seeking to deny V-Money claims. This seems to be most common with anaesthetics and emergency procedures, however it can also be an issue with other specialties.

The key problem is where a registrar (validly) performed a procedure between the time of admission and the time the election was made, on the basis the patient was believed to be public. If the patient later makes a valid – but deferred – election to be private, the VMO generally won’t be able to claim V-Money; and they also won’t be able to seek payment from the patient, their insurer or Medicare because they didn’t actually perform the procedure themselves. This scenario also clearly raises significant professional and medico-legal risks in relation to the care of a patient for whom a VMO is retrospectively deemed responsible.

The AMA has raised this issue a number of times. Our clear position is that if there is uncertainty around the classification, the patient must be treated as public and the VMO claim paid.

So what can YOU do?

DO hold your hospital administration to account. Check whether they have practical and appropriate procedures in place to ensure all patient elections are completed at or before admission, unless there is a legitimate reason for the delay as contemplated by the National Standards (eg, emergency admissions after hours in hospitals where staff are not available to organise the completion of the election form until the following working day; or patient inability to make a valid election at the time of admission due to severe pain, dementia, etc). If the hospital is using apparent loopholes to justify deferred elections, ask them to explain this to you and scrutinise their responses.

DON’T just assume you’ve made a mistake and let rejected V-Money claims slide. If initial elections are changed from public to private, follow this up and ask for what you’re owed. But also remember the proverbial canary in the coalmine: a V-Money rejection may be the first warning sign that your hospital’s admission procedures aren’t working as well as they should; so find out as much as you can and – if you need help – raise your concerns with us for further review against the National Standards.

By Jane Eldridge and Helen Winklemann

PS.

V-Money Claims
The AMA has assisted a number of members in querying V-Money claims. We have been concerned by the practice of LHDs refusing to pay claims while matters are being investigated, sometimes for a period of months. We believe that under the Determination, there is an obligation on the LHD to pay the disputed claim and then investigate, rather than withholding the payment. We will be reporting on this further in coming months.

Find out more about Professional Services at: www.amansw.com.au/professional-services/