Guideline for substantiating personal performance by a consultant physician/specialist in a public hospital

Page last updated: 23 November 2016

What you need to know

Where a service for a patient in a public hospital is billed to Medicare, the hospital consultant physician or specialist may be asked to substantiate the claim.

This guideline outlines what you can do to substantiate that you as a consultant physician or specialist personally performed a referred consultation service on a private patient in a public hospital claimed under the Medicare Benefits Schedule (MBS).

The guideline is not exhaustive and you can respond to a Medicare compliance audit or review using any documents you believe substantiate the concern raised.

However, we may determine more information is needed and request additional documentation to substantiate services you have claimed.

Public hospitals are funded under an arrangement with the Australian Government to provide free public hospital services to eligible patients.

For a Medicare claim to be paid for a patient in a public hospital:
    • the patient must have elected to be treated as a private patient, and
    • the consultant physician or specialist must be exercising their right to private practice when the service is rendered
Consultation refers to professional attendances or consultations as described in the MBS. For example, MBS items 104, 105, 110, 116 and 119. See General Explanatory Note G.12.1 for the complete list of professional attendances available at MBS online.

Read the health professional guidelines about substantiating claims for Medicare compliance purposes before proceeding.

Documents you may use to substantiate a claim

It is expected that consultant physicians or specialists maintain adequate and contemporaneous records of services rendered. Similarly, adequate and contemporaneous records should be maintained when you provide a referral or request for a patient.

To substantiate your claim, provide:
    • an extract from the clinical report - showing you have personally provided the service to the patient. For example, notes in the clinical record made by you during or soon after consultation with the patient
    • a valid referral - clearly showing the patient's name, the date of referral and the name/s of the referring practitioner, specialist and, or consultant physician, and
    • any other documents that you consider may show you personally performed the consultation to the patient on the specific day and time
If you need to use a patient's clinical information you can censor any details that aren't relevant. You can also choose to provide the information to one of our medical advisers.

To understand the special referral requirements for referrals made within a hospital, and for additional information on general referral requirements, refer to MBS explanatory note G6.1, available at MBS online.

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