Below are some common questions about how billing works with Access Gap Cover (AGC).

Can I send a bill directly to my patients?

You cannot give the bill to the patient to take to the fund. If you choose to use AGC, you will need to submit the unpaid claim to the health fund on behalf of your patient.

Can I charge the full amount to my patient up-front prior to claiming from the health fund?

No. If you choose to participate in AGC, you can only ask the patient to pay the gap amount up-front, if there is a gap. Only unpaid AGC accounts can be submitted to the health fund. You are still required to put the total charge on the account to the fund (inclusive of any patient co-payment).

Can I charge a co-payment?

AGC enables you to charge your patients a co-payment of up to $500 per episode if you wish to do so. A written Informed Financial Consent must be provided to your patient prior to the surgery or as soon as possible in emergencies.                   

Please refer to the Billing guide on ‘What is the maximum patient co-payment (allowable known gap)?’ and 'Step 3: Make proper disclosure to the patient - Informed Financial Consent (IFC)'.

Can I charge AMA rates and still use AGC for my patient?

If the gap amount falls within the maximum patient co-payment (allowable known gap), AGC can still be used. Once the charges are above and beyond the defined known gap limits, funds are only obliged to pay benefits up to MBS fee. Refer to the Billing guide section on 'What is the maximum patient co-payment (allowable known gap)?'. Also refer to clause 3 of the AGC terms and conditions.