Evaluation of the National External Breast Prostheses Reimbursement Program

4.3.2 The claiming process

Page last updated: 05 November 2010

Figure 11 below shows that women who participated in the survey used a range of methods for claiming under the program, but that most women obtained a form in person either from a Medicare office (30%) or prosthesis fitter/supplier (24%). One in ten women (10%) downloaded and posted an application form. This supports findings from discussions with other evaluation respondents that prosthesis fitters play a key role in the application process.

The vast majority of claims for the reimbursement made by survey respondents (97%) were successful. A variety of reasons, with no apparent pattern, were given for unsuccessful claims.

Figure 12 indicates that survey respondents were generally satisfied with aspects of the claiming process, nearly 80% agreeing it was straightforward overall and just over 80% agreeing it was easy to gather supporting information for their claim. A similar proportion of respondents agreed that they were treated with sensitivity by Medicare staff while making their claim.

Similarly positive views are indicated by the results shown in figure 13. More than 90% of respondents gave a favourable rating (3 to 5 out of 5) relating to the ease of obtaining, completing and lodging an application form.

It is apparent that older respondents had more difficulty with the claiming process than others.

  • Respondents aged 70 years and over were more likely to disagree that 'the process of getting reimbursed was straightforward' (10%) than those aged 50 to 69 years (7%) or those aged up to 49 years (8%).
  • Similarly, respondents aged 70 years and over were less likely to agree that 'It was easy to gather the necessary supporting information for the claim' (55%) than those aged 50 to 69 years (84%) and those aged up to 49 years (84%).
  • The ease of obtaining a form was rated less favourably by respondents aged 70 years and over (80%) than those aged 50 to 69 years (94%) and those aged up to 49 (93%).
  • The ease of lodging a form was rated less favourably by respondents aged 70 years and over (75%) than by those aged 50 to 69 years (94%) and those aged up to 49 years (87%).
Affordability of the initial payment
Confusion about eligibility and interaction of the program with private health insurance Top of page

Figure 11 – How did you make your claim for reimbursement of an external breast prosthesis? (n=214)


Note that the above figures do not add to 100%. The remaining 21% of respondents completed a postal version of the survey and did not answer this question.

Text version of figure 11

Method

Percentage

I completed the form at a Medicare office30
I completed the form provided by my breast prosthesis supplier24
I downloaded an application form and posted it to a Medicare office10
I called or wrote to a Medicare Office and they sent me a form, which I completed and returned to them4
Other10
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Figure 12 – On a scale of 1 to 5 where 1 is 'strongly disagree' and 5 is 'strongly agree' please indicate how much you agree or disagree with the following statements about the program (n=214)

Text version of figure 12

Statement

Not sure (%)

Strongly disagree (%)

Disagree (%)

Neutral (%)

Agree (%)

Strongly agree (%)

I was treated with sensitivity while making my claimSmall percentageSmall percentageSmall percentage122259
It was easy to gather the necessary supporting information for the claimSmall percentageSmall percentageSmall percentage122160
The process of getting reimbursed was straightforwardSmall percentageSmall percentageSmall percentage121861
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Figure 13 – On a scale of 1 to 5, where 5 is the best score, how would you rate the following aspects of the program? (n=214)

Text version of figure 13

Aspect

Not sure (%)

1 (%)

2 (%)

3 (%)

4 (%)

5 (%)

The ease of completing the application formSmall percentageSmall percentageSmall percentage92263
The ease of lodging the application formSmall percentageSmall percentageSmall percentage92061
The ease of obtaining an application formSmall percentageSmall percentageSmall percentage102258
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Affordability of the initial payment

In figure 14, responses to the more negative statement on affordability of paying up front for breast prostheses were ambivalent, with just over 40% agreeing, just over 25% neutral, and approximately one third disagreeing. This result suggests that there are a broad range of views on this aspect of the program, including a substantial minority who feel it is difficult to afford the upfront payment.

The impact of the upfront payment on the program's participants is discussed further in section 4.3.4.

Figure 14 - Affordability of the initial payment

On a scale of 1 to 5 where 1 is 'strongly disagree' and 5 is 'strongly agree' please indicate how much you agree or disagree with the following statement about the program (n=214)

Text version of figure 14

Agreement with the statement "It was difficult to afford the up-front payment required for a reimbursement under the program" was as follows:
Agreement
Percentage
Strongly disagree21
Disagree12
Neutral26
Agree16
Strongly agree24
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Confusion about eligibility and interaction of the program with private health insurance

Many women reported that they were confused about whether to claim for a reimbursement from their private health insurance, Medicare Australia, or whether to claim through both. There are health insurance providers who provide a lower rate of reimbursement, link the reimbursement for prostheses to other breast cancer related items (therefore jeopardising women's capacity to claim for these other items), or provide no reimbursement for prostheses at all. Breast care nurses interviewed also cited anecdotal evidence of health funds ceasing coverage of breast prostheses since the advent of the program.

A number of different scenarios were mentioned by women (as relayed below). Noteworthy elements in these include an excessive amount of consultation back and forth with Medicare and private providers, difficulty retrieving receipts, and unwittingly losing entitlements due to lack of knowledge of how to navigate the dual claiming process.

"I claimed my prosthesis from my private fund first and was able to get $200 from them and then from Medicare I got $200. Unfortunately this eliminated all of our extra private benefits and if my husband or myself needed more reimbursement for other aides e.g. for teeth, physio etc, then we would not have been able to get any refunds. I feel that the reimbursement should be solely covered by Medicare."

"Having always paid for private health insurance I feel that reimbursement being lower for me was unfair."

"As I was a very early claimant the private insurer/ Medicare office people were unprepared. The big problem was my private health insurer (which had already reimbursed me for a portion of the cost) could not give me back the receipt from the prosthesis provider. I therefore had to go back to the provider to get another receipt before Medicare would cover the difference."

"I was initially rejected by Medicare because I have private health insurance. So I had to apply through my health fund and then contact Medicare. However the health fund wanted my original receipt so I could only supply Medicare with a photocopy. I was rejected for a second time for not having the original receipt. I then had to go back to the prosthesis supplier in order to get a duplicate receipt. Finally Medicare accepted my claim."

"I have private health cover and tried to claim from them first and recover the rest of the cost from the Government reimbursement. I pay for my health (private) cover and do not agree that they are now avoiding their share of the cost – they are not only covering the examination costs, not their basic liability. The Government should insist that we claim from our private health cover first and then pick up the rest."

"The main difficulties for me were with the part of the claim covered by private health insurance… the Medicare part of it was straightforward."

"I am privately insured including ancillary and my health fund stopped reimbursing for prostheses – no explanation was given."

It is clear from these comments that there is a need for the issue to be examined and for the interaction of private cover and reimbursement under the Program to be clarified in communication materials, or streamlined, to ensure a smooth process and consistent outcomes.