OTDs & FGAMS scaling Factsheet

OTDs and FGAMS working in private practice in Australia are subject to the Medicare provider number restrictions set out in section 19AB of the Act. OTDs and FGAMS are required to work in designated districts of workforce shortage (DWS) for a minimum of 10 years (usually referred to as the ‘10 year moratorium’) in order to access a Medicare provider number and Medicare benefits.

A DWS is a geographical area of Australia in which the population’s need for healthcare has not been met. Population needs for health care are deemed to be unmet if a district has less access to medical services than the national average.

Scaling is a non-cash incentive offering OTDs and FGAMS opportunities to reduce the 10 year moratorium restriction period. Time reductions are significantly greater for doctors who choose to work in more remote areas. (See the Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA) table below.)

RA Classification	RA Category	Scaling % discount	Restriction period reduced to
RA 1	Major Cities	Nil	10 years
RA 2	Inner Regional	10%	9 years
RA 3	Outer Regional	30%	7 years
RA 4	Remote	40%	6 years
RA 5	Very Remote	50%	5 years

Scaling began on 1 July 2010 and is not retrospective.

All OTDs and FGAMS are eligible for scaling where:

• their ‘moratorium period’ has begun
• they hold a valid section 19AB exemption for the location where the services were provided (ie. their medical services attracted Medicare benefits)
• they’ve met the total ‘value of claims’ threshold for that month
• services were provided in an eligible ASGC-RA 2 – 5 category.

Note:

• The minimum ‘value of claims’ threshold is $5,000 per month.
• Doctors who don’t reach the minimum threshold will not receive scaling incentives for that period.
• Doctors participating on the 5 Year OTD Scheme should contact their Rural Workforce Agency for further information.

While the scaling system offers opportunities to reduce the 10 year restriction period, it doesn’t replace the requirement for doctors to hold a section 19AB exemption in a designated DWS to access Medicare benefits for their ‘moratorium period’.

Eligibility for a scaling discount is determined by Medicare Australia on a monthly basis. Medicare Australia calculates doctors’ claiming activities in all eligible ASGC-RA locations irrespective of the number of services provided in each category.
The calculation is based on the ‘date of service’ and ‘schedule fee’ of eligible Medicare services. The result determines whether the doctor has met the total ‘value of claims’ threshold of $5,000 for that month.

The ‘schedule fee’ of the following Medicare services is counted toward the total ‘value of claims’ each month:

• all MBS services, including assist at operation item numbers
• DVA (MBS) services
• late claims submitted after the end of a month (the scaling discount is applied retrospectively).

The following Medicare services are not counted:

• act of grace payments
• rejected claims
• bulk billing incentive items.

Where considered eligible each month, doctors receive the scaling discount applicable to the major ASGC –RA category (for that month).
The major ASGC-RA category is determined during the claiming activity calculation. It’s based on the ASGC-RA category location where the highest ‘value of claims’ were processed.

Doctors with a Public Key Infrastructure (PKI) individual certificate will be able to view their scaling progress using Medicare Australia’s Health Professionals Online Services (HPOS).
Register online for a PKI individual certificate
or call Medicare’s eBusiness Service Centre: 1800 700 199
Find out more about HPOS services

Call Medicare Australia on 132 150.

Medicare Australia applies monthly scaling using the date of service for the month being scaled. Monthly scaling identifies any claims with a date of service during the previous three month period.
To ensure all late claims are included, an automated recalculation runs in March and September each year, to identify any additional claims during the previous 6 month period. The automated process collects any additional claims for the previous 2 year period.

Each month, Medicare Australia calculates and displays eligible doctors revised ‘scaled’ end dates in the HPOS system. Doctors can view their progress towards meeting their return of service obligation.
This process continues until the revised scaled end date is equal to the actual date (ie today’s date).
When this happens:

• The doctor has met the return of service obligation under the Act and no longer has to practise in a district of workforce shortage.
• Medicare Australia automatically applies an open-ended ‘scaling class’ 19AB exemption to a doctor’s record that is non-location specific. This allows the doctor to practice in any location.
• For any new locations, doctors will need to apply for a Medicare provider number through Medicare Australia (as all doctors are required to).

Note: Medicare Australia provides written notification to doctors when the ‘scaling class’ 19AB exemption is applied.