Protecting your provider number:
when Medicare comes knocking

Live webinar held 21 November 2019.
Begin watching the recording here.

 

Responses to remaining participants’ questions

By our Risk and Medico-legal advisers


General 

It is not possible to split payments for ‘additional charges’ but it is possible for ‘separate services’.

Refer to Bulk bill payments to health professionals.

No. The clarification on bulk billing has recently been updated on the Services Australia website noted above.

Services Australia can investigate suspected fraud; see “What we do with reports about suspected fraud”.

Legislation is in place which will enable the Department of Health (DoH), once data-matching principles are put in place, to undertake data-matching and sharing arrangements to assist fraud and incorrect claim detection.

Individuals can now also view the activity on their Medicare card via their myGov account.

Usually the two previous years. For Professional Services Review (PSR) and Practitioner Review Program (PRP) audits, the first year is generally used for comparison only.

Most come to the DoH’S attention because the data indicates the doctor is a statistical outlier.

The nature of statistics is that someone sits at the bottom and someone at the top of the bell curve. The DoH uses computer algorithms which pick up statistical outliers. This means that doctors who sub-specialise may come to the department’s attention because their special area of interest places them in a high percentile for a particular item number. That doesn’t mean the doctor is necessarily doing anything wrong, but they are more likely to come under scrutiny.

Medicare audits are based on Medicare Benefits Schedule (MBS) item numbers claimed by each provider. How the patient is billed is not a contributing factor. The DoH are only interested in items billed to Medicare, not your private billings.

This is not our experience (see response above). If there is a common error being made across the practice, which means more than one doctor at the practice is a statistical outlier as a result of the error, they too might become the subject of an individual audit.

You can only bill Medicare for a face to face consultation of that person for a ‘clinically relevant’ service. Therefore, in this scenario if the only reason for the visit was for a child’s results/referral then you could not bill Medicare; however, you could charge the parent a private ‘out of pocket’ fee.

Yes:

Where the referral originates from a practitioner other than those listed in Specialist Referrals, the referral is valid for a period of 12 months, unless the referring practitioner indicates that the referral is for a period more or less than 12 months (e.g. 3, 6 or 18 months or valid indefinitely). Referrals for longer than 12 months should only be used where the patient's clinical condition requires continuing care and management of a specialist or a consultant physician for a specific condition or specific conditions.

From MBS – Note GN.6.16.

From MBS – GN.6.16: “The referral is valid for the period specified in the referral which is taken to commence on the date of the specialist's or consultant physician's first service covered by that referral.”

The date of the referral being written by the GP is not the starting point of the referral period.

MBS – Note GN.6.16 states:

where the referring practitioner –

(a)  deems it necessary for the patient's condition to be reviewed; and

(b) the patient is seen by the specialist or the consultant physician outside the currency of the last referral; and

(c)   the patient was last seen by the specialist or the consultant physician more than 9 months earlier

the attendance following the new referral initiates a new course of treatment for which Medicare benefit would be payable at the initial consultation rates.

If the person is a long-term patient with an ongoing chronic condition, which only requires an annual specialist review and there have been no new/significant changes, then a subsequent consult is appropriate without a new referral.

See the full explanation at MBS – Note GN.6.16.

Further explanation can be found at Services Australia which states:

If a patient needs continuing care, GPs can write a referral beyond 12 months or for an indefinite period.

If a patient on an indefinite referral has a new or unrelated condition, the GP must issue a new referral for that condition.

From Referring and requesting Medicare services.

The actual ‘clock’ on the clinical software record is helpful but not critical. It is more important to thoroughly document the consultation to show the complexity involved.

Legislation requires the practitioner to make adequate and contemporaneous records of the rendering or initiation of services to a patient by a practitioner – and this includes providing sufficient clinical information to explain the service. The record should be completed at the time, or as soon as practicable after, the service was rendered or initiated, and the record must be sufficiently comprehensible to enable another practitioner to effectively undertake the patient’s ongoing care in reliance on the record.

See MBS – Note GN.15.39.

You can only bill Medicare for a face to face consultation of that person for a ‘clinically relevant’ service, the time-based items require you to be actively treating the patient. If the notes are written while you consult with the patient then you can include the time. If you write the notes after the patient has left the consultation then the time taken does not contribute to the consult time.

You should always use your clinical judgement when it comes to sickness certificates (see page 17). You are not automatically required to extend a sickness certificate; however, if it is your clinical opinion that the patient's condition might warrant an additional day, you can extend the certificate. You would need to do so with some confidence as employers/education facilities may question the extension. Because the extension of the certificate is part of the initial consultation, it would make sense to do so free of charge. If the patient had a condition that should have been improving (e.g. a worsening infection despite antibiotic treatment), you would probably want the patient to re-present, rather than simply extending the certificate.

Medicare benefits are generally not payable for health screening services. However, there are circumstances which are included. From MBS – Note GN 13.33:

The Minister has directed that Medicare benefits be paid for the following categories of health screening:

(a) a medical examination or test on a symptomless patient by that patient's own medical practitioner in the course of normal medical practice, to ensure the patient receives any medical advice or treatment necessary to maintain their state of health. Benefits would be payable for the attendance and tests which are considered reasonably necessary according to patients individual circumstances (such as age, physical condition, past personal and family history). For example, a cervical screening test in a person (see General Explanatory note 12.3 for more information), blood lipid estimation where a person has a family history of lipid disorder. However, such routine check-up should not necessarily be accompanied by an extensive battery of diagnostic investigations; …

These types of screening are not payable by Medicare if they are for the purposes of entrance to schools and other educational facilities.

No. The response below has been provided by AskMBS.

With regard to a referred professional attendance by a specialist or consultant physician, Medicare benefits are not payable unless a valid referral has been received prior to the service and the medical practitioner who accepts the referral personally performs the service.

A medical practitioner is legally responsible for services billed under their provider number or in their name, and a Medicare claim should not be made under a practitioner's provider number for a service provided by another practitioner.

Services which do not attract Medicare benefits include telephone consultations (with the exception of the COVID-19 temporary telehealth items), issue of repeat prescriptions when the patient does not attend the surgery in person, nontherapeutic cosmetic surgery, and others.

See MBS – Note GN.13.33.

It is good practice to review your active provider numbers (via your PRODA account) and ‘inactivate’ those you never want to use again. It may be preferable to only inactivate a few weeks/a month after leaving a practice as there may be some rejected billings that need to be re-submitted.

Clause 6 of your Professional Indemnity Insurance Policy with MDA National includes legal costs that we incur on your behalf in assisting you with an investigation – such as a Medicare investigation.

We do not cover a fine or a civil or criminal penalty as per exclusion 20.15(b). This also means we do not cover any amounts you may be required to repay to the Department of Health via a Medicare audit, or through the PRP or PSR.

If the newborn has been enrolled in Medicare but the parents have not received the card you can call Medicare or look up via PRODA/HPOS to get the number. If the newborn has NOT yet been enrolled but is eligible for Medicare you can treat the baby and bill the item later, once you know the Medicare number. Alternatively, you can bill the parents and provide them with an invoice, so they can claim the rebate once the newborn has been enrolled. If the baby is not eligible for Medicare then you can issue a private invoice.


Compliance 

If you receive a letter from Medicare please call MDA National for further advice.

If you are working in a practice, and you have no control over your billings, we strongly recommend you request regular access to billing reports. You are ultimately responsible for your provider numbers so it is your obligation to check your billings and raise any concerns with the practice so any errors can be rectified.

We recommend ensuring that you clearly understand the MBS billing requirements. If you believe that the practice is billing incorrectly then you should put your concerns in writing to the Practice Manager and ask for clarification or reasons for the policy.

We are happy to assist our Members who find themselves in this position.

From Prescribed pattern of services (the 80/20 rule):

A GP or OMP engages in inappropriate practice if they have rendered or initiated 80 or more professional attendance services on each of 20 or more days in a 12 month period (known as a 'prescribed pattern of services'). This is commonly referred to as the "80/20 rule".

The 80/20 rule is based on the number of professional attendance services per day, which may not be the same as the number of patients seen in a day.

Although this may not technically breach the 80/20 rule, it doesn’t mean you are safe from audit. Medicare audits often occur when the DoH’s computer algorithms identify you as a statistical outlier. The more serious audits tend to focus on doctors who are above the 90th percentile for certain items when compared to their peers across Australia.

Not that we are aware of.

It is not possible to request comparison data from the DoH.

Services Australia do provide open access to Medicare item statistics to enable practitioners to view the volume of individual MBS items rendered, including by state and during various time periods. See Medicare item reports.

Medicare audit data includes a section on “Items in Association”. This shows items that are billed to the same patient on the same day that ‘may’ not meet the item descriptor, e.g. several attendances in one day. This may be legitimate but often it is a mistake or a misunderstanding of the rules. Making a genuine error is unlikely to attract a formal review – although it may be a contributing factor if there are other statistical concerns.

Patients are becoming far more informed about services billed to their Medicare card due to the information easily available on myGov. Even if the DoH doesn’t pick up the error, the patient may report their concerns to the DoH who can, and will, investigate on behalf of the patient.

See the Education guide – Billing multiple MBS items.


General practice 

As per the AskMBS ADVISORY #1 Section 4:

Doctors should not conduct a separate consultation for another health-related issue in conjunction with a health assessment unless it is clinically necessary [and] Providers should not bill a health assessment item and additionally bill an individual service that is included as part of the assessment.

Based on this information in some circumstances it may be acceptable but your documentation needs to be clear – and the time associated with the health assessment must not include anything related to the care plan.

In the event of an audit, the DoH will take your location and specialty area of work into consideration.

Ensure you are complying with the descriptor, including claim periods (every 9 months minimum), and have good documentation.

See MBS Note AN.0.43.

There is a description for consult items in the MBS, e.g. a standard level B includes any of the following that are clinically relevant:

(a) taking a patient history;

(b) performing a clinical examination;

(c) arranging any necessary investigation;

(d) implementing a management plan;

(e) providing appropriate preventive health care;

for one or more health-related issues, with appropriate documentation.

The MBS states level A is “… for an obvious problem characterised by the straightforward nature of the task that requires a short patient history and, if required, limited examination and management”.

From MBS Note AN.0.9.

Consultation items for non-VR doctors do have different time requirements than the equivalent for GPs – see MBS Online for descriptors.

The second visit can be billed, but you should add notes into the billing system to indicate the second visit is not related to the first visit.

“You can only bill one attendance item. The second visit was a continuation of the first attendance.” See the Education guide – Billing multiple MBS items.


Mental health 

While the MBS does not specifically prohibit claiming CDM and MH items together the documentation should be comprehensive and clear – and timing of the MH item cannot include any of the CDM plan time. See MBS Note AN 0.56 and question below.

No, the MBS explanatory notes for mental health items states “ … if a consultation is for the purpose of a GP Mental Health Treatment Plan, Review or Consultation item, a separate and additional consultation should not be undertaken in conjunction with the mental health consultation, unless it is clinically indicated that a separate problem must be treated immediately”.

From MBS Note AN 0.56.

You should choose the item most appropriate to the service provided.


Chronic disease management 

Yes, see the AskMBS ADVISORY #1 Section 2 (pages 5–6).

A 732 review of a TCA requires the GP to “consult with at least two health or care providers (each of whom provides a service or treatment to the patient that is different from each other and different from the service or treatment provided by the general practitioner who is coordinating the TCAs or plan) to review all the matters set out in the relevant plan”.

This review is not directly related to providing any further referral to an allied health provider if you have already referred for the 5 visits for the year – but you must have feedback from the minimum two collaborating health providers to allow billing a 732 for the TCA.

From MBS Note AN.0.47.

“To be eligible for any of the CDM items, a patient must have a chronic or terminal medical condition. This is one that has been or is likely to be present for six months or longer ...”

See section 1.3 of the Department of Health Questions and Answers on the Chronic Disease Management (CDM) items for the full explanation.

Yes, on the proviso that he/she agrees to contribute to the plan and provides feedback after seeing the patient.

See section 3.9 of CDM Q&A.

An electrocardiogram can be claimed with a 721/723.

Item 10997 can only be claimed where a GP Management Plan, Team Care Arrangement or Multidisciplinary Care Plan is in place and can be claimed for a maximum of five services per patient in a calendar year. The services provided by the practice nurse or Aboriginal and Torres Strait Islander health practitioner should be consistent with the scope of the patient’s plan.

From section 3.3 of CDM Q&A:

Communication must be two-way, preferably oral or, if not practicable, in writing (including by exchange of faxes or email). It should relate to the specific needs and circumstances of the patient. The communication from the collaborating providers must include advice on treatment and management of the patient.

This communication should then be documented into the plan, e.g. “phoned Dr x on 8.01.01, discussed Pt, continue treatment as per last letter dated 01.01.01”.


Skin excisions 

As per the Education guide - Billing skin lesion treatment and biopsy items under Medicare:

You can bill a malignant excision item twice for the same skin lesion if it requires further excision. You can use malignant skin items for the initial excision of the lesion and, if clinically relevant, the re-excision.

You might need to re-excise a malignant skin lesion:

  • if the original surgical excision was incomplete
  • to ensure you remove an adequate margin of healthy tissue around an excised malignant skin lesion to prevent reoccurrence.

If you perform a re-excision, select the relevant item for the excision diameter based on the defect size.

You need to check the specific item descriptor as they are not all the same in this group, as per MBS Note GN.14.36:

Benefits are not payable for the consultation in addition to an item rendered on the same occasion where the item is qualified by words such as "each attendance", "attendance at which", "including associated attendances/consultations" …

A consultation fee may only be charged if a consultation occurs; that is, it is not expected that consultation fee will be charged on every occasion a procedure is performed.

No.

When a provider bulk bills an MBS item, they are accepting the patient assignment of their Medicare benefit as full payment for the service. Additional charges cannot be raised in relation to a Medicare service being bulk billed, whether for consumables or some other reason.

The one exception to this rule is where the patient is provided with a vaccine or vaccines from the practitioner's own supply, held on the practitioner's premises.

See the AskMBS ADVISORY #1 Section 1.

 

Medico-legal question?

 

This Q&A is generic information only and does not take into account the physical state, medical status and/or health requirements of any particular individual which are relevant to proper diagnosis and treatment of any problem, condition or disorder, nor does the information take into account the particular facts relevant to any legal, financial or workplace issue. We recommend MDA National Members contact us if specific advice is required. We may also refer you to other professional services.