General

How do in-hospital referrals work?

20 January 21

A specialist doctor asked how the various specialists below should claim for their services in this very common scenario. Patient attends the Emergency Department (ED). The ED Dr refers the patient to Dr A and Dr B (of different specialties) for inpatient management of a complex presentation. Dr A performs an initial consultation and is then covered for a few days by Dr C. Dr B performs an initial consultation, which identifies another problem requiring the expertise of Dr D. At the end of the admission, there are outstanding specialist issues that require outpatient follow-up with Drs A and D. 1. Should all four specialists bill using the in-hospital override for all consultations? Can A, B and D all claim a 110 or 132 as reflective of the service they provided? 2. If C identifies a new issue that requires assessment and a change in treatment, can C claim an in-hospital 110 (non locum tenans)? 3. If A and D use an in-hospital override for inpatient claims, and then receive a subsequent Medicare-compliant referral for outpatient review of the issue(s) managed during the admission, does the outpatient review occur “after the end of the period of validity of the last referral to have application” (because the last referral expired at hospital discharge). If so, can they claim a 110?

Can I rely on answers from askMBS@health.gov.au?

10 January 21

Doctor B had received written advice from askMBS which he believed was not only wrong, but likely illegal. He wanted to know if he could rely on the advice. Detailed Reasoning The Department of Health and Aged Care is not a law firm and cannot give legal advice. This is why all askMBS answers come with a comprehensive disclaimer. Only lawyers with a current practicing certificate are authorised to provide legal advice in this country. Medicare interpretation is legal advice. The below court decisions (even though one is about fishing!) make clear that relying on government advice in any setting will not protect you. Ignorance of the law is no excuse. High Court authority In the 2004 High Court case of Ostrowski v Palmer, Mr Palmer had obtained a commercial fishing licence and was found guilty of fishing for rock lobsters in a place where that was prohibited. However, before he did this, Mr Palmer had first sought advice from the relevant state government department, which led him to believe he was allowed to fish there. Mr Palmer raised this as a defence when the case was in court but was unsuccessful. The court held firm on the principle of ignorance being no excuse of the requirement to comply with law. The court stated: “Ignorance of the legal consequences that flow from the existence of the facts that constitute an offence is ordinarily not a matter of exculpation, although it may be a matter of mitigation, and in some circumstances...

Can I bill to Medicare when a patient is in Australia but I am overseas?

8 January 21

Doctor A asked what happens when the treating doctor goes overseas for a week of conference leave while the patient is midway through a course of treatment such as chemotherapy or radiotherapy. The patient cannot stop or delay the treatment because it is required to be administered via incremental doses at set intervals. The doctor wanted to know if billing could continue from overseas under the supervision arrangements.

Can I bill to Medicare when my patient is overseas but I am in Australia?

8 January 21

Doctor A wanted to know whether billing to Medicare was permitted in circumstances where an Australian, Medicare eligible patient, was overseas working or holidaying, and the doctor was in Australia, and the service took place via telehealth.

In a public hospital outpatient clinic does a referral to “Dear Specialist” enable Medicare bulk billing?

21 September 20

Question: If a clinic receives a referral to “Dear specialist” can this be used by anyone in that practice? Or if it comes to a named specialist, can that validly be used by another provider in the same practice? These are privately referred non-inpatient in a public oncology setting that is bulk billed.

Do you get one item 132 and two item 133’s every 12 months?

31 August 20

Doctor A worked in a public hospital outpatient department where they exercised a right of private practice. They thought that they were not automatically permitted to bill item 132 every 12 months but had received contrary advice. Further, they were unclear about whether item 133 applies twice in the first year only or twice every year. They had been further advised that 133 can be billed twice during a 12 month period and therefore, for a patient of 20 calendar years that would mean they could bill item 133 40 times.

Are inpatient and outpatient episodes considered as separate for billing purposes, so that when a patient is discharged a new episode of care automatically commences?

26 August 20

Question: If the same treating rehab physician sees a patient following discharge in their outpatient rooms, can this be billed as a 132 (obviously with a relevant referral), or is it a 133/116 depending on other factors? I’m just not clear if the inpatient and outpatient episodes are to be considered in isolation of each other.

Can a GP with surgical training bill item 41764?

17 August 20

A general practitioner has asked whether they can claim item 41764 given they have appropriate surgical training to perform the procedure, which is a nasendoscopy/sinoscopy.

Can oncologists bill item 14206 and does it come under the supervision rules?

17 August 20

A practice manager for an oncology practice asked whether the oncologists can claim item 14206 even though it is in the assisted reproductive technology (ART) section of the MBS, because it accurately describes a service the oncologists provide, being “HORMONE OR LIVING TISSUE IMPLANTATION by cannula.”

Is a written handover sheet a valid inpatient referral between specialists covering each other on weekends, or does it have to be a formal letter?

4 August 20

Doctor A was a respiratory and sleep physician who had been trying to obtain clarity around this question. The question specifically related to weekend cover when doctors are rostered to cover each other’s admitted patients on a rotating basis. Doctor A said that some groups and individuals seem to apply and interpret the requirements differently, which was of concern to them.

Are annual enrolment or membership fees legal in a bulk billing setting?

1 August 20

Annual enrolment or membership fees have become a controversial feature of bulk billing GP practices in recent years. One example was the now defunct National Health Co-op in the ACT, which publicly charged a $100 per year membership fee and a $30 sign up fee in return for bulk billed services. It was even awarded State based grants to support this business model. However, there is debate around the legalities of these arrangements with the Federal Government expressing the view that such arrangements breach the bulk billing law.

Can I bulk bill a Medicare service and charge for a related non-Medicare service simultaneously?

1 August 20

A gastroenterology practice asked whether a service provider providing two services to a patient on the same day, one for which there is an MBS item number, and the other for which there is not, can bulk bill the MBS service and simultaneously collect private payment for the non-MBS service. The question related to an outpatient context and both services were clinically relevant for the treatment of the patient, meaning neither would be considered cosmetic. NB: The scenario presented in this question is distinct from the common scenario of bulk billing a consultation and charging a private fee for a cosmetic botox injection, which is permitted, because Medicare specifically excludes rebates for cosmetic procedures, which are not clinically relevant. In this scenario, both services are clinically relevant. It is an important distinction and often a point of confusion.

Can a group of specialists operating under a single brand, but with their own separate practices, agree to charge the same fees?

1 August 20

A group of haematologists in private practice, who operate across various locations under a single brand with a central point of contact, asked if they could agree to all charge the same fees. Behind the brand, they each operate their own private practices with separate legal entities, separate ABNs and so on. They also asked if anything changed if they all agreed to bulk bill everyone.

When I am covering another physician’s inpatients and it’s the first time I see the patient, can I bill an initial consultation?

27 July 20

When one physician covers anothers’ inpatients who have already been admitted, but are new to the doctor covering for the weekend, Dr A wanted to know if it is acceptable to bill a 110? Dr A’s instincts were that all encounters should be billed as 116 since they are generally part of the same episode of care, (even if provided by a different physician) but she had received conflicting advice.

If a specialist sees a non-admitted patient in an approved private emergency department, can they bill to Medicare and is the patient entitled to a rebate?

10 July 20

Billing to Medicare for non-admitted patients in public hospital emergency departments is strictly prohibited, even if patients have private health insurance and are happy to use it. This is provided for in various provisions of both the Health Insurance Act 1973 and its intersection with the National Health Reform Agreement. However, in this scenario, Dr A was a haematologist who worked at a private hospital with an approved private emergency department (ED). Dr A wanted to know whether non-admitted patients in the ED could be billed to Medicare and whether the patient would be entitled to a Medicare rebate. Further, Dr A wanted to know at what point a patient is considered an inpatient after a decision to admit has been made, so that the patient’s private health insurer (PHI) could be billed. Was it: 1. When the patient is physically out of the ED and on the ward, or 2. When a decision has been made to admit the patient, but the patient is still in the ED, or 3. When the patient’s admission status has been changed in the hospital administration system indicating the patient is an inpatient.