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Election status and responsibility for care and funding in a complex patient journey

There are many situations that can arise in the administration of Medicare billing in public hospitals. These case studies have been constructed to help you find how you can improve your Medicare billing practices.

Case study

Day 1: A patient sees her GP with concerns about her general health. She complains of feeling tired for the last 3 months, has a poor exercise tolerance and has a palpable lump in her left breast. The GP, after an appropriate history and examination, diagnoses the lump as being suspicious. They then request an ultrasound of the left breast, a full blood count (FBC), and kidney and liver function tests (UEC/LFT). All as MBS-rebated services. The GP then bills MBS item 36 for a consultation lasting more than 20 minutes.

Day 2: The patient has the requested tests conducted, which are claimed under appropriate MBS item numbers.

Day 3: The patient is reviewed by her GP with the results of the ultrasound and pathology. They indicate mild anaemia and a suspicious lesion in the breast. The GP requests a fine needle aspiration (FNA) of the left breast lump to be billed against the MBS. The GP then bills MBS item 36.

Day 7: The patient is reviewed again by her GP with the results of the FNA indicating that the patient has breast cancer. The GP discusses with the patient her option to be a public or private patient when receiving care. Specifically, what this means for the care and costs to the patient and health system. After considering her options, the patient elects to be a public patient at the local tertiary hospital. The patient is referred to the public hospital breast clinic with the referral letter. As per hospital requirements, addressed to the head of the breast clinic, together with all the available results. The GP then bills MBS item 36.

Day 14: The patient attends the public hospital's breast clinic and is seen by the registrar. The registrar discusses the case with the breast surgeon, who reviews the results but does not see the patient. The registrar then requests further pathology and diagnostic imaging (DI) tests under the MBS. The surgeon then bills MBS item 104. The pathology centre and DI/radiology centre do not establish whether the patient is a public or private patient. They also bill for services under the MBS.

Day 21: The patient undergoes surgery as a public in-patient (ABF). While an in-patient, the patient has further pathology and DI services at the contracted (located on hospital premises) providers, all of which are billed to the MBS.

Day 27: The patient is discharged and referred back to the GP with a discharge letter. The hospital asks the patient to see the GP in 3 days for review of the wound and re-dressing of the wound site.

Day 28: The patient’s partner calls the GP practice and advises that the patient is complaining of increasing shortness of breath and chest pain. The GP does a home visit and, after an appropriate history and examination. They suspect deep vein thrombosis (DVT), and sends the patient back to the public hospital by ambulance. The GP then bills item 37.

Is this appropriate?

Day 17: Appropriate as the patient is a general practice patient (MBS).
Day 1427: MBS billing is not appropriate as the patient is a public patient (ABF).
Day 28: Appropriate billing.

Reasons MBS billing on days 14-27 was not appropriate:

A patient should be treated free of charge as a public patient. Unless they have a named referral and they have elected to be a private patient. In this case study, the patient has elected to be a public patient; the named referral does not change this fact. As part of public hospital care, the consultation, pathology and DI are funded through public hospital arrangements and should not be billed to the MBS.

Providers should ensure and clearly document that a patient has elected to be a private patient before billing Medicare. Providers, including those working in pathology and DI in public hospitals may be asked to substantiate that the patient chose to be a private patient. A named referral does not necessarily substantiate that a patient has elected to be a private patient. Guidelines on how practitioners can substantiate services provided under rights of private practice at public hospital outpatient departments can help you avoid similar issues to those in the case study.

Further to not being entitled to bill the MBS for a public patient. The surgeon has not met the requirement of MBS item 104 by simply reviewing the patient's test results. It is a requirement of MBS item 104 that the practitioner personally performs the service. To bill this item, the practitioner must have attended the patient.

The Pathology and DI services should not be claimed under the MBS for hospital services. Even if the referrer has not made it clear whether the patient is public or private. As with other providers, pathology and DI providers are obligated to substantiate whether a patient is entitled to Medicare benefits before billing the MBS. It is noted that most ordering forms for pathology and DI request information on whether the patient is private or public. If in doubt, the provider can ask the hospital or the patient. Note that, by billing Medicare, a provider is stating that the patient is eligible to receive a Medicare rebate.

In asking the GP to conduct a MBS funded post-surgery review in 3 days' time, the hospital has handed over responsibility for wound aftercare relating to a hospital-funded episode to the GP. This is inappropriate. GPs should not be directed in a discharge summary to provide specific treatment (although recommendations can be made).

It is noted that GPs routinely review patients post discharge and, for medico-legal reasons. GPs may not be in a position to immediately refer the patient back to the hospital when they attend the GP's practice. Communication between practitioners can help to avoid concerns around hand-over of publicly funded care becoming systemic. It is recommended that the GP communicate any concerns back to the referring practitioner, discharge officer or the GP liaison in the hospital.

All of the payments in this period would be duplicate payments.

Explanation of the appropriateness of day 28:

The GP has claimed an MBS item during what would generally be considered a care period relating to a public episode. However, the claim is appropriate because:

  • the GP service was independently sought, that is not referred or recommended by the hospital. For a matter that was not routine aftercare (note: practitioners should notate the account as ‘not normal aftercare’)
  • the service was not part of the requested review/hand-over of aftercare
  • the public hospital had no involvement in, or knowledge of, the service.

Key Points

  • Each practitioner and provider of services must understand the election status of the patient. To presume that their own arrangements, such as rights to private practice, determines whether they can bill Medicare for services.
  • It is the responsibility of the provider to determine that the patient is eligible for Medicare benefits before making any claims. This includes establishing that the service has not been funded elsewhere, as per section 19(2) of the Health Insurance Act 1973. Which states that Medicare benefits are not payable for services that are otherwise arranged or funded by the Commonwealth or state governments.
Last updated: 
9 June 2021

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