Medicare Provider Numbers: Provider Beware

In the event of inaccurate or inappropriate billing, the practitioner will be liable.

Responsibility for billing arrangements

Increasingly, Staff Specialists and Visiting Medical Officers (VMOs) in the public hospital system are asked to authorise hospital staff to bill non-admitted patients for services provided to those patients using the Staff Specialists’ and VMOs’ Medicare Provider Numbers. These billing arrangements are often conducted with minimal input from the Staff Specialist or VMO concerned.

In general practice, it is practice staff who are usually responsible for billing patients. General practice billing continues to grow in complexity given the breadth of services that GPs provide to patients. While there are more opportunities for GPs (and specialists consulting in private practice) to be involved in the billing process than there is for medical practitioners in the public hospital system, there are a number who rely heavily on practice staff. Medical practitioners need to ensure they are aware of the billing practices being undertaken on their behalf.

In the event that incorrect and/or inappropriate billing on behalf of a medical practitioner does occur, Medicare and/or private health insurers will hold the medical practitioner concerned responsible regardless of who conducted the billing on their behalf. Medicare will seek recovery of incorrectly and/or inappropriately billed services from the medical practitioner as provided for under the Health Insurance Act 1973 and any applicable private health insurance fund rules.

If the medical practitioner wishes to pursue the medical practice or hospital for the money, this will be a matter for that medical practitioner, not a matter for Medicare or the health funds.

In addition to the possible repayment of money, engaging in inappropriate billing may have more serious consequences for practitioners including, in some cases, a period of suspension from Medicare.

Risk management strategies

Suggested strategies to minimise risk where billing is conducted by others on behalf of a medical practitioner include the following:

• Any direction from hospital administration or practice administration regarding the conduct of billing and compliance with Item Number requirements should be in writing, and should be retained by the medical practitioner in the event of a Medicare or private health insurer audit. If in doubt about a direction given, seek advice from MDA National.

• Where possible, medical practitioners may wish to have their own staff conduct billing in order to retain some control over the billing process.

• Medical practitioners should give clear directions to staff regarding Item Number requirements, and it is the medical practitioners who should determine whether the requirements for the Item Number for a service have been met.

• Medical practitioners should conduct regular audits of the billing undertaken on their behalf to identify any issues or concerns.

• Medical practitioners should seek and retain records of billings (date and time of service, Item Number, justification for clinical requirements of Item Number) in the event of an audit.
  

Finally, before entering into private practice billing arrangements in the public hospital system, medical practitioners should seek advice regarding the possible consequences prior to entering into such arrangements, to satisfy themselves that the proposed arrangements comply with the provisions of the Health Insurance Act 1973 and/or the National Healthcare Agreement.