Medicare for New Health Professionals

Transcription

1 Please note this is a text only version and doesn t contain many of the live features of the elearning interactive program. If you wish to access the elearning interactive program, click here. Medicare for New Health Professionals This program is recommended for all new health professionals who are or will be participating in the Medicare program. It provides an outline of the fundamentals of the Medicare program and includes an assessment module to test your understanding of the learning material. PAGE 1 OF 55

2 elearning Terms and Conditions You must read and accept the following terms and conditions before you access and use the elearning training materials. By using this site you agree: 1. The information contained on this site and the elearning training materials, which include but are not limited to programs and modules, is provided for educational, communication and information purposes only and Human Services is not providing you with any recommendations or advice whatsoever. 2. The information contained on this site and the elearning training materials is intended to provide general information only and you must not rely on this information in any way. Specific information is contained in applicable legislation and regulations which includes (without limitation and as amended, replaced or repealed from time to time): The Health Insurance Act 1973(Cth) and its Regulations The National Health Act 1953 (Cth) and its Regulations Public Governance, Performance and Accountability Act 2013 Veteran's Entitlement Act 1986 (Cth) The Dental Benefits Act 2008 drug and poisons Acts and Regulations applicable in the States and Territories. All legislation covered in the elearning programs can be accessed at or and as a professional provider of health services you need to determine how this information applies to your particular circumstances. 3. Information contained on this site and the elearning training materials will not replace or constitute medical advice or treatments. 4. To exercise your own skill, care and clinical judgment with respect to using the information contained on this site and in the elearning training materials. 5. Human Services accepts no responsibility for the accuracy, completeness or authenticity of information contained on the site, in the elearning training materials and any website links provided. 6. Human Services does not accept any responsibility for any loss or damage suffered by you as a result of using this site, the elearning training materials or links provided, including, but not limited to, any loss or damage resulting from: a. Your reliance on any information contained in the elearning training materials, and b. Any damage to your hardware or software, and you release Human Services from any liability so arising. PAGE 2 OF 55

3 7. References to websites are provided for information only and do not constitute endorsement of those websites by Human Services. Omission of websites should not be construed as non-endorsement by Human Services. 8. Human Services does not guarantee that any of the materials referred to will be available at any particular time. 9. You are responsible for your use of any third-party software in connection with using the elearning training materials. 10. Generic medicine and brand names are used as examples for learning purposes only and their use is not intended to influence clinical or therapeutic decisions. There is no express or implied endorsement by Human Services. 11. The PBS examples provided in the elearning training materials are for education purposes only and are not to be relied upon as being current. For current PBS information, please refer to Reference to non-pbs prescriptions in the elearning training material are for educational purposes only and are not to be relied upon as being current. Human Services has no interest in prescriptions for medicine written as non-pbs prescriptions or medicine obtained without prescription. 13. The Medicare item examples provided in the elearning training materials are for education purposes only and are not to be relied upon as being current. For current MBS information, please refer to The Child Dental Benefits Schedule (CDBS) item examples provided in the elearning training materials are for education purposes only and are not to be relied upon as being current. For current CDBS information, please refer to the Dental Benefits Schedule in the Dental Benefits Rules 2013 at Human Services may make changes to elearning training materials at any time with or without notice. You accept all such revisions by accessing any part of the site or continuing to access it after that revision is posted on the site. 16. This elearning training material is copyright. You may download, display, print and reproduce this material in an unaltered form only (retaining this notice) for your personal, non-commercial use. Except as permitted above, you must not copy, adapt, publish, distribute or commercialise any material contained in the elearning training materials without Human Services permission. 17. The copyright in the materials accessed through the site links remains with the author of those materials, or the author s licensee, subject to the operation of the Copyright Act 1968 (Cth). PAGE 3 OF 55

4 18. All requests and enquiries concerning reproduction of elearning training materials and rights are to be posted online at: or addressed to: External Communication PO Box 1001 Tuggeranong DC ACT These terms and conditions are governed by the laws of the Australian Capital Territory. Both parties submit to the jurisdiction of the courts of the Australian Capital Territory. 20. Use of the site is at your own risk. All express or implied warranties, representations, statements, terms and conditions relating to your use of the site or any information or content available from the site, not contained in these terms and conditions, are excluded from these terms and conditions to the extent permitted by law. 21. Your personal information is protected by law, including the Privacy Act If you provide feedback using the online evaluation form, Human Services will collect any personal information you provide in the form and the address you use to send the form for the purpose of evaluating the elearning program. Your information may be used by Human Services or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information about the way in which Human Services will manage your personal information, including our privacy policy at humanservices.gov.au/privacy or by requesting a copy from Human Services PAGE 4 OF 55

5 Module 1 Introduction to Medicare This module provides you with an overview of the Australian health care system, focusing on the Medicare program. It outlines the basic program eligibility requirements for health professionals and patients, including when Medicare benefits can be paid. Topic 1: The Australian Health Care System The Australian Health Care System The national health care funding system gives eligible Australian residents, regardless of their personal circumstances, access to health care at an affordable cost or at no cost, while allowing choice for individuals through substantial private sector involvement in health care delivery and financing. The Australian health care system includes a mixture of public and private sector health services. The Australian Government's health funding includes three major national subsidy schemes: Medicare - Australia's universal health care program the Pharmaceutical Benefits Scheme (PBS) the Federal Government Rebate on private health insurance. Medicare and PBS cover eligible Australian residents and subsidise their payments for private medical services and for a high proportion of prescription medicine. Australian Government funding of the rebate on private health insurance supports people's choice to take up and retain private health insurance. Medicare Medicare provides access to: free or subsidised treatment by health professionals such as doctors, specialists, optometrists, dentists and other allied health practitioners (in special circumstances only) free treatment and accommodation as a public (Medicare) patient in a public hospital 75 per cent of the Medicare Schedule fee for services and procedures if you are a private patient in a public or private hospital (does not include hospital accommodation and items such as theatre fees and medicines). PAGE 5 OF 55

6 Federal, State or Territory and local government responsibilities The Australian Government has the primary role of developing national policies, regulations and funding. Australia's public hospital system is jointly funded by the Australian Government and state and territory governments. State, territory and local governments are responsible for the delivery and management of public health services and for maintaining direct relationships with most health care providers, including the regulation of health professionals and private hospitals. The (Human Services) and Department of Health (DoH) Human Services works in partnership with DoH to achieve the Australian Government's health policy objectives. Human Services makes payments for services provided by eligible health professionals under Medicare, the PBS and other programs (such as the Australian Childhood Immunisation Register). DoH is responsible for the policy development of the Medicare program and the Medicare Benefits Schedule (MBS), and Human Services is responsible for administering the Medicare program on behalf of DoH including: registering the details of health professionals eligible to have Medicare benefits paid for their services assessing and paying Medicare benefits to eligible members of the public for a range of medical services detecting and preventing fraud and abuse of the Medicare program. References above: registering To access Medicare benefits, you must register with Human Services and meet specific criteria. This is covered in the next topic, Health Professional Eligibility. paying Medicare benefits to eligible members Medicare enrolments and Medicare benefit payments are administered by Human Services through electronic channels. PAGE 6 OF 55

7 Topic 2: Health Professional Eligibility Health Professional Eligibility from one of the following options To be eligible to provide services which will attract Medicare benefits you must meet the requirements as described below. Medical practitioners General practitioners Specialists Consultant physicians To be eligible to provide medical services which will attract Medicare benefits, or to provide services for or on behalf of another practitioner, you must meet one of the following criteria: a. be a recognised specialist, consultant physician or general practitioner; or b. be in an approved placement under section 3GA of the Health Insurance Act 1973; or c. be a temporary resident doctor with an exemption under section 19AB of the Health Insurance Act 1973, and working in accord with that exemption. Any practitioner who does not satisfy the requirements outlined above may still practice medicine but their services will not be eligible for Medicare benefits. NOTE: i) New Zealand citizens entering Australia do so under a special temporary entry visa and are regarded as temporary resident doctors. ii) It is an offence under Section 19CC of the Health Insurance Act 1973 to provide a service without first informing a patient where a Medicare benefit is not payable for that service (i.e. the service is not listed in the MBS). Non-medical practitioners Allied health professionals Dentists Dental specialists Participating midwives Participating nurse practitioners. To be eligible to provide services under MBS items relevant to your profession, you must be: a. registered according to State or Territory law or, absent such law, be members of a professional association with uniform national registration requirements; and b. registered with Human Services to provide these services. PAGE 7 OF 55

8 Note: Audiologists may either be a 'Full Member' of the Audiological Society of Australia Inc (ASA), who holds a 'Certificate of Clinical Practice' issued by the ASA; or an 'Ordinary Member - Audiologist' or 'Fellow Audiologist' of the Australian College of Audiology (ACAud) Note: For more information on eligibility requirements for Medicare (evidence of registration or association membership), refer to the provider number application form or contact the Medicare provider enquiry line on (call charges apply). Page What is a provider number? A provider number is a unique number that Human Services issues to eligible health professionals who apply to participate in the Medicare program. It consists of eight characters made up of both alphas and numerics. Your provider number identifies: you and your eligibility to have Medicare benefits paid for eligible services you provide the location from which you render services your eligibility to refer or request services for Medicare purposes. You must have a provider number for every location at which you practise. If you move to a new practice location, you must apply for a provider number for that new location. How to apply for a provider number? 1. Complete the provider number application form for your profession. You can download application forms from the Human Services website. 2. Gather together any supporting documents required. 3. Fax or post the completed form and copies of your supporting documents to Human Services (the fax number and postal address details are on the form). You should send your application and supporting documents to Human Services prior to your proposed commencement date. You should not commence billing until Human Services has advised you of your provider number and Medicare billing eligibility. PAGE 8 OF 55

9 References: Prior The processing of applications for a provider number can take up to 30 days depending on the type of application submitted. You should contact the Medicare provider enquiry line on (call charges apply) for information on when your application should be lodged with Human Services. Note: If you require assistance completing your application or are unsure of what documents you need to supply, contact the Medicare provider enquiry line on (call charges apply). Conversation Health Professional Eligibility Dr Lee's provider eligibility for Medicare commences on 1 May. The practice manager at the surgery where he will be working has contacted him about the possibility of him starting before 1 May. Practice Manager Dr Lee, are you able to start a few days earlier? One of the other doctors at the practice has had to travel interstate at the last minute and we really need someone to take her place as soon as possible. Dr Lee I can start earlier but my services won't be eligible for Medicare benefits before 1 May. I could see patients for non-medicare services such as commercial driver licenses if you wish? Do your services attract a Medicare benefit? Having a provider number does not necessarily mean you can attract Medicare benefits for the services you provide. The Health Insurance Act 1973 sets out the legislative requirements you must meet before your professional services can attract a Medicare benefit. When you apply for a provider number, Human Services will advise of any restrictions that may apply to you. If the service you are providing does not attract a Medicare benefit, it is important to inform your patient. It is an offence under the Health Insurance Act 1973 to provide a service without first informing a patient when a Medicare benefit is not payable for that service. Note: If you have questions about your eligibility to access Medicare benefits for services you provide, you should call the Medicare provider enquiry line on (call charges apply). PAGE 9 OF 55

10 Using your provider number in day-to-day activities To enable the payment of Medicare benefits, all accounts lodged with Human Services must include your name and either: your provider number for the location where you provided the service or the address of the practice location at, or from, which the service was given. To refer your patients to another health professional (for example, a specialist or allied health professional) or request diagnostic imaging or pathology services, your referral letter/form or request must include your name and: your provider number for the location where the referral or request was written and/or the address of the practice location at, or from, which the referral or request was written. Note: Include your name, provider number and practice address to ensure prompt payment of Medicare benefits. Notify Human Services promptly when you stop practising from a location. Failure to do so could result in misdirection of payments or other information. Working in place of another health professional (locum tenens arrangements) A locum is a health professional who temporarily fulfils the duties of another. As mentioned earlier, you must have a provider number for every location at which you practise. However, if you are working as a locum in a new location you may be able to use one of your existing provider numbers. If you are unsure of the requirements for working in place of another health professional, you must contact the Medicare provider enquiry line on (call charges apply) to discuss your options. PAGE 10 OF 55

11 Topic 3: Patient Eligibility Under the Health Insurance Act 1973, a patient is eligible for Medicare benefits if they: meet the definition of either an Australian resident or an eligible overseas representative or have been declared eligible by a Ministerial Order or are a visitor from a country with which Australia has signed a Reciprocal Health Care Agreement (RHCA). Australian residents Australian citizens, holders of permanent resident status and some applicants for permanent resident status who reside in Australia are eligible for a Medicare card. Residents of Norfolk Island are not eligible for enrolment in Medicare. Eligible overseas representatives Permanent employees of government agencies who are posted overseas for varying periods of time to act as agency representatives remain eligible for Medicare as they are Australian citizens. Ministerial Orders The Health Insurance Act 1973 allows the Minister to order a particular person or group of persons to be regarded as eligible for enrolment in Medicare, even though they would not ordinarily meet the eligibility criteria. Reciprocal Health Care Agreements (RHCA) The Australian Government has signed an RHCA with the governments of several countries which entitles residents of these countries to limited subsidised health services for medically necessary treatment while visiting Australia. The countries are New Zealand, Republic of Ireland, United Kingdom, Netherlands, Sweden, Finland, Norway, Italy, Malta and Belgium. The entitlements and periods of cover under these agreements vary for different countries. Newborn babies Newborn babies are eligible for Medicare once eligibility of at least one parent, proof of birth and Australian residency requirements have been met and provided to Human Services. PAGE 11 OF 55

12 The importance of the Medicare card Before a patient can access the free or subsidised treatments available through the Medicare program, they must have a valid Medicare number. This number is recorded on the Medicare card the person will receive when they enrol. Exceptions Eligible visitors from New Zealand or the Republic of Ireland are not issued with a Medicare card. They are entitled to access public hospital services as a public patient only by presenting their passports before treatment. Eligible visitors from other countries with a RHCA can present either their passport or Medicare card when accessing public hospital services as a public patient. For health professionals in private practice, possession of a valid Medicare card is an indicator of the patient's eligibility to receive Medicare benefits for any eligible services you provide. Reading the Medicare card The Medicare card is comprised of three key components (11 numbers in the two parts that uniquely identify each person, name and the expiry date) digit number on the Medicare card identifies the cardholder and their family groups. The last digit identifies the latest issue number for the card for example, issue 2 supersedes issue 1. 1 Individual reference number. John A Citizen VALID TO 02/2012 Name of eligible person. Card expiry date. Note: You will need to quote the patient's Medicare card number in order to use some of the billing methods available from Human Services. PAGE 12 OF 55

13 Reciprocal and Interim Medicare cards On the Medicare card issued to an eligible overseas visitor (yellow) or an applicant for permanent residence (blue), 'Reciprocal health care' or 'Interim card' will respectively also appear on the card. PAGE 13 OF 55

14 Topic: Summary In this module you have covered the following: Human Services administers a number of health programs on behalf of the Australian Government Medicare provides eligible Australians with affordable, accessible and high quality health care Medicare benefits are paid for professional services provided by eligible medical practitioners, participating optometrists, dentists (specified services only), allied health professionals, and nurse practitioners and midwives provider numbers are important for uniquely identifying you as a health professional and the location from which you are practising your patient must have a valid Medicare card number in order to access Medicare benefits for health professional's accounts. PAGE 14 OF 55

15 Module 2 Introduction to the MBS Item numbers, descriptors, explanatory notes - what do these terms mean? How will knowing about them help you in your everyday work? Find the answers to these questions and more in this module of the training. Topic 1: The Medicare Benefits Schedule (MBS) What is the MBS? Introduction to the Medicare The MBS is a Department of Health (DoH) publication which is updated regularly. It contains a listing of the Medicare professional services subsidised by the Australian Government. The MBS is your source of information about MBS service requirements and benefits. The MBS is available at and can be accessed directly using the MBS Online search facility or by downloading a version of all, or part, of the MBS. Structure of the MBS The MBS is comprised of general explanatory notes and several categories. These categories are structured to group professional services according to their general nature. Each category contains explanatory notes specific to its services, and where necessary, an index to assist in finding the appropriate item for the service provided. Category 1 Professional attendances Information on medical practitioner and optometrical attendances, including attendances for the purposes of health assessment and chronic disease management. Category 2 Diagnostic procedures and investigations Information on diagnostic services such as electrocardiogram, audiology and respiratory services. PAGE 15 OF 55

16 Category 3 - There are two parts to category three: 1. Therapeutic procedures Information on surgical operations, obstetric services and a wide range of other therapeutic procedures; and 2. Relative Value guide for anaesthesia Information on Anaesthesia services. Category 4 Oral and Maxillofacial services Information on oral and maxillofacial services by approved dental practitioners. Category 5 Diagnostic imaging services Information on diagnostic imaging services (for example, x-ray, ultrasound, MRI and CT scanning). Category 6 Pathology services Information on pathology services, including some basic pathology services that general practitioners can directly provide to their patients. Category 7 Cleft lip and cleft palate services Information on professional services in respect of the treatment of cleft lip and cleft palate conditions. Category 8 Miscellaneous services Information on eligible allied health services such as diabetes education, physiotherapy and podiatry. It also outlines services that can be provided by Aboriginal and Torres Strait Islander health practitioner and practice nurses on behalf of medical practitioners. Note: An index is included in the publications of the MBS available at PAGE 16 OF 55

17 Requirements before a Medicare benefit is payable If you provide a professional service that is listed in the MBS, a Medicare benefit is only payable when: the patient is eligible to receive benefits (as outlined in the Patient eligibility topic in the Introduction to Medicare module) you are registered with Human Services and eligible to attract benefits for the service provided (as outlined in the Health professional eligibility topic in the Introduction to Medicare module) the service is medically necessary and clinically relevant for the management of the patient's condition. References Clinically relevant A clinically relevant service is one that is generally accepted by the relevant profession as being necessary for the appropriate treatment of the patient. Note: It is an offence under the Health Insurance Act 1973 to provide a service without first informing a patient when a Medicare benefit is not payable for that service. What do items look like in the MBS? Each professional service contained in the MBS has been allocated: a unique item number an item descriptor a Medicare schedule fee (referred to in the MBS as 'Fee') a reference to any explanatory notes relating to the item, where applicable. Index of services Where you are using a hardcopy or downloaded PDF version of the MBS, an index of services is generally provided within each Category to assist you in locating the appropriate item number for the service provided. Note: Medicare benefits are not payable for a service not listed in the MBS. However, there are some procedural services which are regarded as forming part of a consultation or else attract benefits on an attendance basis. For example: injection of sclerosing fluid for treatment of varicose veins can only be billed as an attendance item. Procedures payable as attendance item are listed in the index with an asterisk * against their description of service. PAGE 17 OF 55

18 What do items look like in the MBS? Below is an example taken from MBS Online of the information you would find for the item number Scroll over each of the boxes with blue borders for more details. Item number: This is the unique number allocated to this professional service and the number you would use to bill for this service. Item descriptor: The item descriptor tells you the service requirements you must meet before you can claim this item. Medicare schedule fee: This 'Fee' is used as the basis for the benefit calculation. Explanatory notes: Some items have additional explanatory notes to further guide you on the service requirements. Please select from one of the following options MBS item explanatory notes The item descriptor outlines the service requirements you must meet before you can bill a MBS item. However, some professional services are more complex than others. To provide you with more guidance, certain items include additional explanatory notes. Explanatory notes explain the service requirements in more detail and outline the range of treatments and/or assessments you need to provide to meet the requirements for billing a service. Below is an example item which has explanatory notes. Read the item descriptor and then scroll over the box below with the blue border (A17) to see how explanatory notes assist in clarifying the service requirements you would need to meet for this item. References Before you can bill Incorrect use of MBS items can result in penalties, including the health professional being asked to repay monies that have been incorrectly received. Therefore, it is extremely important that you understand the full requirements of each professional service, prior to billing a MBS item. PAGE 18 OF 55

19 MBS item fees Each MBS item is allocated a 'Fee' (see highlighted area in the example below). Item fees are determined by DoH and are uniform across Australia. These fees are used as the basis for all benefit calculations. Health professionals are able to set their own level of fees for services. However, the Medicare benefit for the service will be based on the MBS fee. References Fees These fees should not include goods or services that are not part of the specified item. Inappropriate billing practices are covered in the Billing and Claiming module. How are Medicare benefits calculated? Introduction to the Medicare As previously mentioned, Medicare benefits are based on a percentage of the 'Fee' for each service as listed in the MBS. In general: out-patient GP based attendance items attract 100 per cent benefit all other out-patient services attract a benefit of 85 per cent in-patient services attract a benefit of 75 per cent. Refer to the item example below. If an eligible health professional provided this service to their patient as an out-patient service and issued an account for $110.00, the Medicare benefit payable would be $75.10 with an amount owing from the patient of $ If the service was provided to an admitted patient as part of an episode of hospital treatment (other than as a public patient), the Medicare benefit payable would be $66.25 with an amount owing from the patient of $ PAGE 19 OF 55

20 Topic 2: Searching the MBS Online MBS Online MBS Online is a useful tool to search the MBS by item numbers and keyword/s. It contains the latest MBS information as it is updated as changes to the MBS occur. When you log onto MBS Online, the 'Search MBS' field is displayed as shown below. Searching the MBS Online by item number An example of searching by item number is shown below. Performing a search by item number is a simple as: 1. Keying the item number (in this case 30061) into the 'Search MBS' field. 2. Selecting the 'Search Item numbers only' radio button. 3. Clicking the 'Search' button. Searching the MBS Online by item number This search for Item has returned the following details. Searching MBS Online by keyword An example of searching by keyword is shown below. To perform a search by keyword(s): 1. Key a keyword or keywords (in this example - ''audiogram') into the 'Search MBS' field. 2. Select the 'Search All' radio button. 3. Click the 'Search>' button. Searching MBS Online by keyword This search has returned seven matches which contain the keyword 'audiogram', a snapshot of which is displayed below. To help you decide which item number is appropriate for the service provided, your next step would be to read the descriptor for each of the matches, including the explanatory notes where relevant. Note: Further guidance on searching the MBS Online can be found on the Department of Health "Search the MBS - Hint Sheet". PAGE 20 OF 55