Physicians warned of Medicare billing risks in hospitals


By Julie Lambert

1 Jun 2021

Physicians have been warned of a Medicare crackdown on inappropriate double-billing for patients in hospital settings.

The Federal Health Department updated its Medicare Billing in Public Hospitals webpage to highlight “concerns” about duplicate payments claimed for MBS services that would be already covered by the National Health Reform Agreement between the Commonwealth and states and territories.

Key points are that Medicare benefits are not payable for services provided to a public patient in a public hospital, and a public hospital must not assume that a patient who has private insurance will automatically elect to be admitted as a private patient.

It is particularly important to establish the public or private election status of a patient where referred or requested services, imaging or testing is provided, the Health Department advice emphasises.

“Health practitioners should actively manage referrals, requests and claiming arrangements to ensure services are not paid for twice through public hospital and MBS funding,” it says.

It is also important for physicians to consider whether the service could be part of pre-care (eg tests prior to admission) or aftercare (follow-up) relating to a public episode that should be funded as a public service, the Health Department warns.

The RACP and other peak bodies have been working worked with the department to produce new guidelines to clarify the rules and help clinicians avoid double-billing. As the following case studies show, however, the devil is in the detail.

In the first example, Ms A is admitted as a private patient at a public hospital with a fractured forearm. She has an asthma attack and is referred to a respiratory physician, Dr C, whose hospital registrar reviews Ms A and arranges treatment of her asthma. Doctor C does not personally attend the patient.

Dr C bills MBS item 110 for a consultation because Ms A is a private patient and was seen by his registrar, a trainee physician accredited by the RACP. Dr C is in the wrong.

The department explains:

  • Registrars are not considered specialists for the purposes of claiming Medicare benefits and cannot provide a referred initial attendance for a patient.
  • If the registrar provides an initial attendance on behalf of the physician, neither the registrar nor the physician can bill for this service.
  • Referred consultation services will attract Medicare benefits only if the consultant physician who bills for the service actually personally performed the service.
  • If the service is performed by another doctor employed by the hospital – the registrar -Medicare should not be billed.

Other examples of inappropriate Medicare billing include a child admitted as a public patient who was billed by a gastroenterologist for removal of a button battery and a cellulitis patient billed for four attendances by a physician even though he saw the consultant only twice – on admission and discharge.

The department advises clinicians to get legal advice if uncertain about contractual or payment arrangements that could lead to infringements of the legislation.

“Practitioners should consider seeking their own legal advice on any risks associated with particular arrangements when providing private services in a public hospital,” it said.

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