Case studies for services provided under rights of private practice at public hospital outpatient departments

Page last updated: 31 March 2016

Case Study 1

Mrs Y is experiencing severe back pain. Her general practitioner provides her with a valid referral to a named specialist at her local public hospital outpatient clinic.

Mrs Y arrives at the outpatient clinic and chooses to be treated as a private patient by Dr N. Dr N is a neurosurgeon at the public hospital and has an agreement in place that allows him to exercise his right of private practice during his hours in the outpatient clinic. Dr N completes a comprehensive examination of Mrs Y and orders further tests.

Dr N bills the patient for the examination under Medicare.

Is this correct?

Yes. Under the National Health Reform Agreement, an eligible patient who presents at a public hospital outpatient department must be treated free of charge. However, if the patient has been referred to a named specialist who is exercising a right of private practice the patient can choose to be treated as a private patient.

Mrs Y, who has a valid referral, chose to be treated as a private patient. Mrs Y was then examined by Dr N who has an arrangement with the public hospital to exercise his rights of private practice during his hours in the outpatient clinic. Therefore the service provided by Dr N is eligible for the payment of Medicare benefits.

Case Study 2

Dr E is an endocrinologist employed by a public hospital with no arrangement in place to exercise right of private practice. Mr D attends the outpatient clinic with a referral from his general practitioner and chooses to be treated as a private patient. Dr E personally reviews Mr D and writes a letter back to Mr D’s general practitioner outlining his findings and proposed treatment.

Dr E bulk bills the patient services under Medicare.

Is this correct?

No. Dr E’s employment conditions do not provide for right of private practice. He cannot bill under Medicare for services he provides at a public hospital.

Mr D had a referral valid for the purposes of billing MBS consultation items and he chose to be treated as a private patient at the outpatient clinic. However, as Dr E does not have a right of private practice, the service is still not eligible to be billed under Medicare.

All requirements must be satisfied for a service to be eligible for payment of Medicare benefits.