A guide to Medicare compliance processes

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2021 is well underway, and with the new year we have seen an increase in member enquiries in relation to Medicare compliance processes.

Private Patient Billing for Out-Patients in Public Hospitals

Under the National Health Reform Agreement, patients must be given the choice to receive public hospital services free of charge as public patients, access to public hospital services is to be provided based on clinical need and within a clinically appropriate timeframe, and arrangements are to be in place that ensure equitable access to services.  

Private out-patient services can be provided in public hospitals provided:

• Patients are given the choice to be treated as public or private;

• Public patients must be provided with the same access to services as private patients;

• If a patient chooses to be treated as a private patient, they must have been referred to a named medical specialist;

• Informed financial consent must be provided to patients.

Referral pathways must not be controlled so that a named referral is a pre-requisite to access out-patient services. A patient must be able to access out-patient services as a public patient.

NSW Health will be publishing a Guideline to provide guidance for NSW Health organisations when billing for privately referred non-inpatients services in NSW public hospitals. The Guideline reflects the position under the National Health Reform Agreement and the Health Insurance Act 1973. 

Medical practitioners are responsible for ensuring that services billed under their provider number are billed in accordance with the requirements of the Health Insurance Act and the Commonwealth Medicare Benefits Schedule. With respect to Visiting Medical Officers and Staff Specialists, providing private patient services in public hospitals this means:

• Regularly reviewing Medicare claims submitted by the hospital on their behalf. If anomalies are identified they should be raised with the hospital and Medicare. 

• Claims should only be made under a Visiting Medical Officer’s or Staff Specialist’s Provider Number if that person provided the service. Services provided by other practitioners should not be claimed under the Visiting Medical Officer’s or Staff Specialist’s Provider Number.

Visiting Medical Officers should also be aware that if a claim is submitted to Medicare for a medical service, a Visiting Medical Officer should not be paid under his or her Visiting Medical Officer Contract for the provision of that service (other than in limited circumstances where an exemption has been given by the Department of Health).  

Billing for Out-Patient procedures

Some members have recently been contacted by the Department of Health in relation to the billing undertaken for out-patient procedures. 

Under the provisions of the Health Insurance Act, the Medicare benefit payable for a service provided as a part of an episode of hospital treatment is 75% of the Schedule Fee. 

Hospital Treatment, for the purposes of the Health Insurance Act, is treatment, inter ala, that is provided at a hospital. No distinction is made as to whether a patient is an in-patient or an out-patient when they receive treatment.

DOH calling doctors

We understand that the Department of Health has recently begun contacting medical practitioners about how and by whom private patient billing is undertaken in public hospitals.

If you receive such a call, we would like to hear from you. 

Shared Debt Recovery Process

The shared debt recovery process may be of assistance to practitioners who are formally audited by the Department of Health. It is not available to medical practitioners who complete a Voluntary Acknowledgement of Incorrect Payments after receiving correspondence from the Department of Health asking the practitioner to review his or her billings.

If you are considering making a voluntary repayment should you become aware of an inappropriate billing practice at your hospital, please contact your MDO or AMA (NSW)’s Workplace Relations Team at workplace@amansw.com.au for advice.