Case studies for consultation services under Medicare in public hospitals

Page last updated: 22 January 2016

Case study 1

Mrs Y was admitted as a private patient at her local public hospital with a fractured forearm and is treated by Dr S, an orthopaedic surgeon.

While in hospital Mrs Y has an asthma attack and Dr S refers her to Dr R, a respiratory physician. Dr R’s registrar reviews Mrs Y and arranges for appropriate treatment of her asthma.

Even though Dr R did not personally attend Mrs Y, Dr R bills MBS item 110 for a consultation because Mrs Y is a private patient.

Is this correct?

No. Referred consultation services will attract Medicare benefits only if the consultant physician who bills for the service is the person who actually personally performed the service.   If the service is performed by another doctor employed by the hospital, Medicare should not be billed for this service. As the consultation service was provided by Dr R’s registrar and not Dr R personally, Medicare benefits are not payable for this service.


Case study 2

Miss T visits Dr D, a dermatologist at her private practice rooms. Dr D has admitting rights to the local public hospital and so arranges for Miss T to be admitted for her condition. Miss T elects to be admitted as a private patient under Dr D.

The next day Dr D sees Miss T on the ward and arranges for further investigations.  Dr D records her clinical findings and treatment plan in Miss T’s clinical notes.

Dr D billed MBS item 104 for the initial consultation provided at her private practice rooms and then she bills MBS item 105 for the subsequent consultation provided in the hospital.

Is this correct?

Yes. Miss T is an admitted private patient and Dr D personally performed both the initial consultation and the subsequent consultation. Dr D has maintained adequate and contemporaneous clinical notes of the services provided to Miss T.


Case study 3

Mr Q is suffering from cellulitis and is an admitted private patient at his local public hospital where he stayed for four days. Dr C the consultant physician performed an initial consultation in the medical ward on day one, with junior medical staff reviewing and attending to Mr Q during his stay on days two and three. Dr C attended, reviewed and discharged the patient sending him home on day four.

Mr Q received the hospital bill for item 110 (initial attendance) and three charges for MBS item 116 (subsequent attendance).

Mr Q is unsure about the bill because he only saw Dr C on two occasions – on the day he was admitted and on the day he was discharged. Mr Q contacts Dr C’s office to question the account. The practice manager tells him, that as an admitted private patient he must be charged for each day that he was in hospital. Mr Q is still unsure and contacts the department to see if the billing is correct.

Is this correct?

No. Referred consultation services will attract Medicare benefits only if the consultant physician or specialist who bills for the service is the person who actually renders the service.

As Dr C personally rendered the patient’s initial consultation on the day of admission to hospital, he can bill item 110 to Medicare for this service. Similarly, as Dr C personally rendered the service on the day of discharge from hospital, he can bill item 116 to Medicare. On days two and three the patient was reviewed only by the hospital’s junior medical staff. Dr C cannot bill Medicare for services he did not personally render.


Case study 4

Mrs Z takes her son to a public hospital emergency department because he has just swallowed a button battery. The child is admitted and undergoes an endoscopic removal of the button battery performed by gastroenterologist, Dr G. The child is observed and discharged the next day.

The next month when Mrs Z checks her myGov account for medical services provided to her son, she is surprised to find that her son received a bulk billed consultation from Dr G. She is concerned because her son was admitted as a public hospital patient. Even though they have private health insurance, as it was only a short stay, Mrs Z explicitly signed the hospital administration form to say that her son was to be admitted as a public patient. Mrs Z contacts the department to make a complaint.

Is this correct?

No. Medicare benefits are not payable for services provided to a public patient in a public hospital.

Eligible patients have the right to elect to be admitted as a public patient regardless of their private health insurance status. Public hospitals must not assume that a patient who has private insurance will automatically elect to be admitted as a private patient. A patient election must be made in writing on the basis of informed financial consent.