Case studies for claiming Medicare in public hospitals when exercising rights of private practice

Page last updated: 31 March 2016

Case study 1

Mr J broke his ankle playing soccer and has elected to be admitted to his local public hospital as a private patient for surgery. Mr J is treated under Dr O, an orthopaedic surgeon. Dr O has an agreement that allows him to exercise his right of private practice at the hospital for his private patients. Dr O operates on Mr J at the public hospital exercising his right of private practice.

Dr O bills the patient for the surgery under Medicare.

Is this correct?

Yes. Under the National Health Reform Agreement, public hospital services are provided free of charge, until the patient has elected to be admitted as a private patient. Mr J was admitted under Dr O as a private patient and Dr O was exercising his right of private practice at the time when he operated on Mr J. Therefore it is correct for Dr O to bill under Medicare.

Case study 2

Dr C is a cardiologist employed by a public hospital. She is a full time salaried employee of the public hospital with no right of private practice. Mrs S was admitted for monitoring and investigation of chest pain. Mrs S was admitted under Dr C, who was the cardiologist on call that day. Mrs S elected to be treated as a private patient.

The public hospital bills the consultation services provided by Dr C to Mrs S under Medicare using Dr C’s provider number.

Is this correct?

No. Dr C is not eligible to bill for services under Medicare to Mrs S or any other patient because her employment conditions do not provide for a right of private practice. Dr C is legally responsible for all services billed to Medicare under her provider number. In the event of an audit, Dr C will have to substantiate the services claimed under Medicare and may be liable for any incorrectly claimed benefits.