To bill or not to bill?

Mar 18, 2016

Is it legal for doctors to use their provider numbers for private patients in public hospitals?

We have received calls from doctors from country NSW to suburban Queensland who have been asked to use their provider numbers to bill Medicare for private patients. This has prompted a number of questions about whether this practice is legal and what happens if Medicare questions the billings.

Is it legal for me to use my provider number so the public hospital can obtain Medicare benefits?

You should only allow your provider number to be used for services that you provide. It is not appropriate for your provider number to be used for all of the patients who attend the outpatient clinic on a particular day if you do not see them.

However, under the National Health Reform Agreement between the federal and state governments, it is legal for public hospitals to charge Medicare-eligible patients for their care in accordance with the principles stated in the agreement.

The basic requirements are that:

  • patients are eligible for Medicare services
  • they are given the choice to access care on a public or private basis
  • they are provided with informed financial consent about their decision and elect in writing to be treated as a private patient
  • there are appropriate referrals if required, for example, to a named doctor in an outpatient clinic
  • the doctors treating the patients have rights of private practice (as is the case with VMOs) and bill in accordance with the Medicare/MBS requirements.

Can the public hospital force a patient to be billed privately?

No. Under section 20 of the National Healthcare Agreement 2012, states and territories have to provide health and emergency services through the public hospital system to eligible patients. This means that eligible patients have the right to receive free treatment.

When a Medicare-eligible patient is admitted to a public hospital via the emergency department, all services provided before the admission must be provided on a public patient basis. Likewise, an admitted patient should be treated as a public patient until they make a valid written election to be treated as a private patient.

The same principles apply to outpatient clinics where patients are given the choice to be treated as public or private patients.

Once a patient makes a valid election to be treated as a private patient, the treating hospital doctor can charge Medicare for his or her treatment in accordance with the MBS schedule, with the benefits paid directly to the hospital.

If my provider number is being used, who is responsible for repaying Medicare if a payment is rejected?

You will be personally responsible and accountable to Medicare for any items billed under your provider number.

We reiterate, you should only allow your provider number to be used for services or professional attendances that you provide.

There are some limited circumstances where your provider number can be used for services provided by, for example, an intern or registrar who is acting under your direct supervision and where you have had a direct involvement with the patient. It is not appropriate for your provider number to be used for all the patients who attend the outpatient clinic on a particular day if you do not see them.

We have been informed recently by doctors that Medicare has contacted them to check if they had seen a patient in an outpatient clinic as a result of the use of their provider numbers. If this happens, you will need to be able to substantiate your involvement in the patient’s care by reference to, for example, extracts from the patient’s medical record confirming you provided the service.

If you are audited by Medicare, you are legally responsible to repay any benefits that have been incorrectly paid under your provider number regardless of whether the hospital arranged the billing or received the benefits. This may include an administrative penalty.

It is therefore important to obtain the hospital’s confirmation in writing that their billing arrangements do not contravene the National Healthcare Agreement and Medicare requirements, and they will assume responsibility for any repayments to Medicare.

This article was first published in Australian Doctor. Read the original article here.

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