Private Patients in Public Hospitals: The Results Are In…

Private Patients in Public Hospitals: The Results Are In…

AMA (NSW) surveyed members about concerns and issues surrounding private patient billings across the public hospital system. Here’s what we found.

AMA (NSW) has been concerned for several years about the many members who contact us expressing concern about a lack of oversight of private patient billings, particularly in outpatient settings, but also for private inpatients, the use of Medicare Provider Numbers without consent, changes in patient election after admission and refusals to remunerate members for services provided to Medicare ineligible patients.

During the state election campaign, the Minns Government committed to a Special Commission of Inquiry into Health Funding. AMA (NSW) has again raised concerns with the Ministry of Health – particularly given the proposed Special Commission – and recently surveyed members to gain an understanding of current concerns and issues when it comes to private patient billings across the public hospital system in New South Wales.

Visiting Medical Officers and Staff Specialists have always, and remain, responsible for billings under their Medicare Provider Number. The concern of AMA (NSW) is that it appears to be the case that for some consultants in the public hospital system, there is little opportunity for oversight and / or control over services billed under their Medicare Provider Number.

There were 345 survey responses. Of those, 210 identified as Visiting Medical Officers (VMOs) and 135 as Staff Specialists.

80 VMOs said they had signed a Privately Referred Non-Inpatient Agreement (PRNIA), and 24 said they had not. Of concern was the number of comments made by respondents saying that they were unsure how to answer the survey questions because they had very little, if any, understanding of how the billing of private patients was done at their hospital particularly for out-patients.

Of the 80 VMOs who had a PRNIA, 59% said the LHD undertook billing on their behalf. The vast majority said they were never provided with the opportunity to review billings before they were submitted on their behalf. Again, many of the comments reflected that there was much confusion about how billing was done.

In relation to private inpatients, for those VMOs for whom the LHD billed these patients, 88% said they never saw claims before they were submitted on their behalf. Only 3.5% said they were always provided with claims to review. Nearly 90% of Staff Specialists said the LHD billed private patients on their behalf, and of those 71% were never provided with billings to review before submission of same to Medicare, 17% were sometimes provided with claims to review and only 12% were always provided with the opportunity to review claims.

Respondents expressed concern and anxiety about the legal implications for them arising from billing practices in public hospitals. A few respondents indicated they had been the subject of Medicare audits and felt pressured by their hospital to admit the errors were theirs when they had not had any oversight of the billings submitted, and to the extent they had, this was provided some time after the claims had been submitted and there was no information provided as to what had been paid and what had not.

Others said they had become aware of their LHDs billing services under their Medicare Provider Number without consent (including when on leave) and / or without a named referral (in outpatient clinics). Others said their LHD policy was that all outpatients were to be billed under Medicare. When questions were asked, it was difficult to obtain information from the hospital concerned. Others reported billings being attributed to the incorrect consultant.

There were 164 respondents to questions regarding change of patient election. 37% of these said their LHD retrospectively changed patient election from public to private. 61% said this happened some of the time, and 21% said this occurred frequently.

Comments from respondents reflected that a number felt that the retrospective change of election effectively compels consultants to no-gap and others commented that administration staff told patients they would not be out-of-pocket regardless of the billing policy of the consultant/s involved.

AMA (NSW) will continue to advocate for changes to private patient billing practices on behalf of VMOs and Staff Specialists to ensure they are not left at risk because of billing practices in the public hospitals, and that they are informed about the private patients under their care so they can meet their professional obligations. To the extent that consultants are placed at risk, AMA (NSW) will be asking the government for the appropriate indemnities.

Contributed by AMA (NSW)’s Director Workplace Relations Advisor, Dominique Egan