Case studies for pathology and diagnostic imaging services in public hospital emergency departments

Page last updated: 02 February 2016

Case study 1

Mrs Y attends her local public hospital’s emergency department with pelvic pain. As part of the hospital’s initial administration process in triage, Mrs Y signs the election form to be treated as a private patient if she ends up being admitted. Dr E, an emergency doctor, examines Mrs Y and orders a pelvic ultrasound, rendered by radiologist Dr D. Upon review of Dr D’s report, Dr E makes a clinical decision to admit Mrs Y and a bed is requested. 

Dr D bills the patient for the ultrasound examination under Medicare.

Is this correct?

No. Emergency patients are to be treated as public patients until a clinical decision to admit has been made and the patient has elected to be admitted as a private patient. Although Mrs Y elected to be treated as a private patient, the ultrasound was rendered before the clinical decision to admit. The service was therefore not eligible for payment of Medicare benefits.

Case study 2

Mr Z attends the emergency department of his local public hospital with a rash. Mr Z is examined by Dr E, the emergency doctor, who makes a clinical decision not to admit him. Before discharge from emergency, Dr E writes a request for a blood test, gives the form to Mr Z and tells him that he should make an appointment to be seen at the hospital dermatology outpatient clinic a week after he has his blood test done. Mr Z has the blood test done at the hospital’s pathology department by Dr P. 

Dr P bulk bills the patient for rendering the pathology test under Medicare.

Is this correct?

No. Emergency department patients cannot be referred to an outpatient department to receive services from a medical specialist exercising a right of private practice. A pathology department in a public hospital can be considered as an outpatient department if it provides outpatient services. These services cannot be billed to Medicare regardless of whether Dr P has rights to private practice or not. Dr P was not eligible for payment of Medicare benefits for this particular service.

Case study 3

Mr Z presents with vomiting and abdominal pain at the emergency department of his local hospital. Dr E, the emergency doctor, examines Mr Z and requests an abdominal x-ray. Mr Z’s symptoms deteriorate and Dr E makes a clinical decision to admit him immediately. Mr Z then signs the election form to be treated as a private patient and is admitted to a ward. Mr Z is taken from the ward to the radiology department to have his x-ray and the result is reported by the radiologist, Dr D. 

Dr D bills the patient for the x-ray under Medicare.

Is this correct?

Yes. Non-admitted emergency patients are to be treated as public patients until a clinical decision to admit has been made and the patient has elected to be admitted as a private patient. The diagnostic imaging service was rendered after Dr E had made a clinical decision to admit Mr Z, and Mr Z had elected to be treated as a private patient. The service is therefore eligible for payment of Medicare benefits.

Case study 4

Mr U is experiencing severe left flank pain and attends the emergency department of his local hospital. Dr E, the emergency doctor, examines Mr U and requests a renal ultrasound. Mr U is taken from the emergency department to the radiology department to have his ultrasound which is reported by the radiologist, Dr D. Mr U’s symptoms deteriorate and after viewing the results of the ultrasound, Dr E makes a clinical decision to admit Mr U, who then signs the election form to be treated as a private patient. 

Dr D bills Mr U’s ultrasound to Medicare.

Is this correct?

No. Non-admitted emergency patients are to be treated as public patients until a clinical decision to admit has been made and the patient has elected to be admitted as a private patient. The diagnostic imaging service was rendered before Mr U had elected to be treated as a private patient and the emergency doctor, Dr E, had made the clinical decision to admit. The service is therefore not eligible for payment of Medicare benefits.

Case study 5

Mrs V attends her local public hospital’s emergency department with pelvic pain. As part of the hospital’s initial administration process in triage, Mrs V signs the election form to be treated as a private patient if she ends up being admitted. Dr E, an emergency doctor, examines Mrs V and orders a pelvic ultrasound, rendered by radiologist Dr D. Dr D is employed by a radiology company, Rays R Us, which provides outsourced radiology services to the public hospital under contract with the hospital. Upon review of Dr D’s report, Dr E makes a clinical decision to admit Mrs V and a bed is requested. 

Dr D bills the patient for the ultrasound examination under Medicare.

Is this correct?

No. Non-admitted emergency patients are to be treated as public patients until a clinical decision to admit has been made and the patient has elected to be admitted as a private patient. Although Mrs V elected to be treated as a private patient, the service was rendered before any clinical decision to admit her. The service was therefore not eligible for payment of Medicare benefits. 

It is irrelevant that the service was outsourced.

Case study 6

Mr X arrives by ambulance at a public hospital emergency department. Mr X is an elderly man with a history of diabetes and appears disorientated. Dr E, the emergency doctor, decides to admit Mr X and blood is taken for an urgent pathology request. After the pathology results are received from the pathologist, Dr P, the patient is transferred to a ward. When on the ward, Mr X’s relatives arrive and complete an election form on his behalf to be treated as a private patient. 

Dr P bills the pathology service to the patient under Medicare.

Is this correct?

Yes. Non-admitted emergency patients are to be treated as public patients until a clinical decision to admit has been made and the patient has elected to be admitted as a private patient. Mr X was not in a position to make a decision on election and next of kin did this on his behalf once they arrived at the hospital and were informed about his condition. Mr X’s pathology test was rendered following a clinical decision to admit. Although Mr X’s admitted patient election occurred after the pathology service was rendered, the election applies to the whole episode of care, starting from admission.

The National Health Reform Agreement recognises that some patients may not be fit to sign an election form and provides for their legally authorised representatives to make the election. When the valid election is made for Mr X, the election is considered to be effective from to the time Mr X is admitted.

Case study 7

Mr V attends his local public hospital’s emergency department with a swollen right ankle following a fall on the stairs at home. As part of the initial administration process in triage, Mr V signs the election form to be treated as a private patient if he ends up being admitted. Dr E, an emergency doctor, notes that Mr V is a haemophiliac and will need to be admitted. Dr E then orders an x-ray which is rendered by radiologist Dr D. 

Dr D bills the patient for the x-ray under Medicare.

Is this correct?

Yes. Non-admitted emergency patients are to be treated as public patients until a clinical decision to admit has been made and the patient has elected to be admitted as a private patient. Mr V’s election to be treated as a private patient and clinical decision to admit takes place before the x-ray has been rendered and is therefore eligible for Medicare benefits.

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