For claiming

1. You will need to have received your hospital provider number issued to you by the Department of Health, this is separate to receiving a state code.
   See circulars at https://www.health.gov.au/news/phi-circulars?utm_source=health.gov.au&utm_medium=callout-auto-custom&utm_campaign=digital_transformation
2. Once you have your hospital provider number, you will need to link the provider number to your Minor ID.
   We will assist you in this step and send you the necessary Medicare forms to complete, but this can not be started until you receive your hospital provider number.
3. Also, we can not start your ECLIPSE registration with each fund until you receive your hospital provider number. We will also initiate this process for you.

 

Coder

New hospital operators coming from a clinic environment, may not be aware of the hospital patient workflow which is:

• Pre-admit
• Admission
• Discharge
• Coding
• Grouping
• Billing

The coding step in the workflow, is done by a trained coder. The coder will look at the medical record and then assign the ICD diagnosis and procedure codes to the episode. These are not MBS codes, they are a totally different set of international codes.

For you to be able to send a claim to the health fund each episode needs to be coded. So you will need to hire a staff member that has the ability to code or what most hospitals do is hire a contract coder to do the coding once a week or a fortnight.  We do not recommend having a coder come in once a month, as this will affect your cashflow.

If you need some recommendations for coders, let us know and we will send you names and contacts of coders used by our hospital community.

 

Grouper Software

As well as each episode needing to be coded, the episode will also need to be grouped. The act of grouping assigns the episode with a DRG, which stands for Diagnosis Related Group. This is an international grouping standard. If you do not assign the episode with a DRG, you will not be able to submit the claim via ECLIPSE, it is just a mandatory field.

Usually a coder once they complete the coding, will click a button within FYDO that will pass the patient details as well as the ICD codes set by the coder to the grouper software. The grouper software will assess the data and return back an appropriate DRG. This will then get saved within FYDO for that particular episode.

The ICD codes and the DRG code get sent to the fund along with the invoice information.

FYDO has integrated with the TurboGouper grouping software. If you need the grouper software, please let us know and we can organise a license for you. The grouper is currently $961+ GST per annum (Price is accurate as of 16 Aug 2023 but is subject to change depending on supplier pricing).

There are some instances where the coder can assign the DRG themselves, we tend to find this possible in very niche disciplines. Best to discuss this with your coder and see if they require you to purchase the grouper or not.

 

Health Fund contracts

What you charge in a hospital setting is totally different to what you charge in the rooms. Most of the time you will want to seek 2nd tier accreditation at a minimum, otherwise you may need to charge minimum benefits. Ideally you want to negotiate a contract with each fund, however not all funds entertain this with brand new hospitals, they may make you wait a year or so.

We have some contacts that specialise in health fund negotiations, let us know if you want some contacts to help you with this.

 

Register your hospital with the governing bodies for monthly reporting

A private hospital needs to report data for each episode of care at the end of each month. Data needs to be reported to:

1. PHDB – Private Hospital Data Bureau (data sent to the Commonwealth)
2. HCP – Hospital Casemix Protocol (data sent to each health fund)
3. State Health, i.e. NSW health, QLD Health etc (data sent to state where the hospital resides in)

Please visit our wiki page Data Extracts Setup