Is it legal
for doctors to use their provider numbers for private patients in public
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
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.
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
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
- 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.
public hospital force a patient to be billed privately?
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
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
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
This article was first published in Australian Doctor.
Read the original article here.
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