The ‘12-month rule’ has been in effect again since 21 October 2021. Our GP Adviser Dr Jeannie Knapp has unpacked the implications for GPs.
What is the 12-month rule?
Since 20 July 2020, GPs and other medical practitioners working in general practice can only provide rebated telehealth where they have an existing and continuous relationship with a patient (also known as the 12-month rule). Patients can only access rebated telehealth services under the Medicare Benefits Schedule (MBS) through their regular GP or practice.
This means patients are eligible for rebateable telehealth services from GPs and other medical practitioners only if they have seen their GP or another medical practitioner or health practitioner (such as a practice nurse or Aboriginal and Torres Strait Islander health worker) face-to-face within the same practice at least once in the preceding 12 months.
This requirement does not apply in areas subject to stay-at-home orders, which were in effect across Victoria for much of 2021. However, the rule came back into effect in metropolitan Melbourne at 11.59pm on Thursday, 21 October 2021 when stay-at-home restrictions were lifted.
How is this different to Commonwealth hotspot declarations?
The Commonwealth hotspot declaration applies to the special COVID long phone telehealth items, and not to the 12-month rule. However, this also ended for most of Victoria recently – on 31 October 2021.
Why were these rules introduced?
To ensure patients continue to receive quality, ongoing care from a practitioner who knows their medical history and needs.
Are there any exceptions?
The rules don’t apply to:
- patients diagnosed with COVID-19 who are isolating at home
- returned Medicare-eligible overseas travellers in hotel quarantine, whose health care is not being provided by a State or Territory government
- close contacts of a confirmed COVID-19 case who have been directed to self- isolate
- patients who have been tested for COVID-19 and are awaiting their result
- from 1 July 2021, accessing new MBS items specific to services for blood-borne viruses and sexual or reproductive health
- infants (under 12 months old)
- people who are homeless
- people living in COVID-19 ‘impacted area’ – which currently does not apply in Victoria
- patients receiving an urgent after-hours (unsociable hours) service
- patients of medical practitioners at an Aboriginal Medical Service or an Aboriginal Community Controlled Health Service
What about new patients to my practice?
Patients who are new patients to the practice will be required to have a face-to-face visit with a practitioner in the practice prior to being able to access MBS rebated telehealth items from that practice. This also applies to existing patients of the practice who have not had a face-to-face visit within the previous 12 months.
A new patient insists on a telehealth appointment as their first contact. Can I claim the MBS?
No. As they have not had a face-to-face appointment with yourself or another practitioner at your practice within the past 12 months, you cannot use an MBS item for the telehealth consult.
We recommend having policies in place for your booking processes to ensure that new patients have a face-to-face appointment as their first contact with the practice.
Patients can of course elect to have a non-rebatable visit – although this will apply to all aspects of the consultation. For example, if they request a mental health treatment plan, as you cannot claim an MBS item, the treatment plan will not trigger the psychology rebate.
What about existing patients who have not been seen for more than 12 months?
Existing patients who have not been seen face-to-face in the past 12 months will require a face-to-face visit to be able to claim a Medicare rebate in subsequent telehealth appointments.
Essentially, all patients require at least one face-to-face visit every 12 months to be able to continue claiming Medicare rebates for telehealth appointments.
We recommend updating your booking processes to ensure patients are warned of the possibility that if they have had no visit in the previous 12 months, they may not be eligible for a rebate. This can be a note on your online booking service, or from receptionists when booking an appointment.
MBS representatives have already audited several practices for non-compliance with this rule, and unfortunately there is often no easy way to highlight those who are eligible/ineligible. Ultimately it is up to the doctor doing the billing to make sure their billings are compliant. We recommend – as a final safety net – that the treating doctor checks for eligibility prior to making the call. You could also consider getting receptionists to call and notify patients of ineligibility if this is discovered.
HealthPathways Melbourne 
Visit the COVID-19 MBS items pathway on Health Pathways Melbourne for more information on the COVID-19 MBS items.
Are you a GP or health professional in our region who doesn’t have access to HealthPathways Melbourne? Request access online or contact info@healthpathwaysmelbourne.org.au
