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is contained in applicable legislation and regulations which includes (without limitation and as amended, replaced or repealed from time to time): The Health Insurance Act 1973(Cth) and its Regulations The National Health Act 1953 (Cth) and its Regulations Public Governance,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

21 Topic: References and Summary References The MBS is available at Searching the MBS Online Introduction to the Medicare mbsonline.gov.au Search the MBS - Hint Sheet Summary In this module you have covered the following: the MBS contains a listing of professional services subsidised through Medicare by the Australian Government and can be accessed at the MBS is divided into a number of categories according to their general nature - for example, diagnostic imaging services and pathology investigations the publications of the MBS contain indexes that will assist you in identifying the appropriate item number, or you can search MBS Online by either an item number or keyword/s each Medicare service is allocated a unique MBS item number. To bill a MBS item you must be confident that you have fulfilled all of the service requirements as specified in the item descriptor and explanatory notes not all services you provide will attract a Medicare benefit. In general, a Medicare benefit is payable for medically necessary and clinically relevant services. PAGE 21 OF 55

22 Module 3 Billing and Claiming This module will explain generic aspects of patient billing and the different claiming and payment options. It also outlines the information required on itemised accounts, receipts and bulk bill claims for billing purposes as well as record keeping requirements. Topic 1: Billing and Claiming Options Medicare Billing options As a health professional you have two options for billing Medicare services: 1. bulk bill or 2. issue private accounts. The differences between the two options will be explained in this module. The Medicare claiming option you or your practice chooses can make a big difference to productivity, cash-flow and patient service. Bulk billing If you choose to bulk bill, you accept the Medicare benefit as full payment for the service(s) provided. When you have provided the service: your patient assigns their right to the Medicare benefit to you you claim the benefit from Human Services Human Services pays the benefit directly to you or your practice. If you bulk bill your patient, with the exception of certain vaccines, no other charges can be raised for the service(s) you provide. This includes booking fees, administration fees, charges for bandages, record keeping or any other charge raised by your company. A time limit of two years applies to the lodgement of claims. This means that Medicare benefits are not payable for any service where the service was rendered more than two years earlier than the date the claim was lodged with Human Services. References exception This exception only applies to general practitioners and other non-specialist practitioners for attendance items 3 to 96, 5000 to 5267 (inclusive) and only relates to vaccines that are PAGE 22 OF 55

23 not available to the patient free of charge through Commonwealth, state or territory funding arrangements or available through the PBS. The additional charge must only be to cover the supply of the vaccine. Two years In certain circumstances, this time limit may be waived. For more information call the Medicare provider enquiry line on (call charges apply). Issuing private accounts Please select from one of the following options If you choose to issue private accounts to your patients: you are able to set your own level of fees for services. You may choose to charge above the Medicare benefit which means your patient will incur an out-of-pocket expense. your patient is responsible for settling their account and claiming the Medicare benefit. To assist your patient make their claim for benefits, you must supply a properly itemised account and/or receipt. References Fees These fees should not include charges for goods or services that are not part of the specified item. Patient or another responsible person, for example if your patient is a child. This person is known within Human Services as the 'claimant'. Options for issuing private accounts The following options are available to you when issuing private accounts. 1. The patient pays the account in full and then uses the account and/or receipt to claim the Medicare benefit. 2. The patient pays you the difference between the Medicare benefit and the account total, then: a. lodges the account/receipt with Human Services b. waits for Human Services to post a 'pay practitioner' cheque c. forwards the Medicare cheque to you to finalise the account. PAGE 23 OF 55

24 3. The patient claims from Human Services using the unpaid account by: a. lodging the account with Human Services b. waiting for Human Services to post a 'pay practitioner' cheque c. forwarding the Medicare cheque together with the difference between the cheque and account total to you. Electronic claiming The following electronic claiming options are available for both bulk billing and when issuing private accounts: Medicare Online Medicare Easyclaim ECLIPSE Some advantages of electronic claiming include: faster lodgement times for Medicare claims together with faster payment times when Medicare benefits are paid via Electronic Funds Transfer (EFT) directly into a nominated bank account. more certainty around lodgement of 'pay practitioner' cheques (if applicable) automatic concession entitlement checking easier for your patients to make claims on-the-spot. Note: Further details on the electronic claiming options can be obtained by contacting Human Services on (call charges may apply) and speaking to a Business Development Officer. References ECLIPSE Electronic Claim Lodgment and Information Processing Service Environment ECLIPSE is an extension to Medicare online claiming and may be used to submit inpatient medical claims to both Medicare and health funds. PAGE 24 OF 55

25 Claiming responsibilities It is important that health professionals provide the required claiming information otherwise the payment of Medicare claims could be delayed or disallowed. The claiming information required to be submitted for bulk bill claims and private accounts is covered further in this module. You must take full responsibility for the information provided on bulk bill claims and private accounts. This includes when someone other than yourself records the information on your behalf, for example, the practice manager. Where you provide, or initiate, a service for which a Medicare benefit is payable, you should make sure that you maintain adequate and contemporaneous records. References adequate To be adequate, the patient or clinical record needs to: clearly identify the name of the patient contain a separate entry for each attendance by the patient for a service and the date on which the service was rendered or initiated provide clinical information adequate to explain the type of service rendered or initiated at each attendance be sufficiently comprehensible that another practitioner, relying on the record, can effectively undertake the patient's ongoing care. contemporaneous To be contemporaneous, the patient or clinical record should be completed at the time the service was rendered or initiated, or as soon as practicable afterwards. Records for hospital patients are usually kept by the hospital and the practitioner could rely on these records to document in-patient care. PAGE 25 OF 55

26 Topic 2: Bulk billing and claiming Bulk billing options for lodgement You can choose to submit your bulk bill claims via: Manual processing - this involves submitting claiming paperwork to Human Services Medicare Online claiming (internet based) - no paperwork is submitted to Human Services Medicare Easyclaim (using existing Electronic Funds Transfer at Point of Sale [EFTPOS] terminal) - no paperwork is submitted to Human Services. Bulk bill claims should be lodged as soon as practicable after the service is rendered. Bulk billing manual processing If you are submitting your bulk bill claims manually, there are two Medicare forms to complete: 1. bulk bill vouchers and 2. bulk bill headers. The forms you use will depend on your profession and the type of service provided. For example, forms are available for: allied health professionals GPs optometrists. For a complete list of bulk billing forms click here. Whichever form is used it is important to include all the necessary details. Note: Bulk bill vouchers may also be referred to as assignment forms. Bulk bill headers may also be referred to as claim forms. Itemised bulk bill vouchers manual processing The example bulk bill voucher below shows the minimum service details required to facilitate the payment of benefits. PAGE 26 OF 55

27 References 1 The patient's name. 2 The patient's Medicare number. Where the patient indicates that they have been issued with a card but do not know the details, you may contact the Medicare provider enquiry line on (call charges apply) to obtain the Medicare card number. Alternatively, if a patient's Medicare number is not available, you must include the patient's name, date of birth and current address on the voucher. 3 Patient's reference number (identifies the individual named on the card). 4 The date on which the service was provided. 5 The MBS item number and/or a description of the service sufficient to identify the item. 6 The Medicare rebate in respect of each item claimed. 7 Additional information to support claim. For example, where you are claiming for more than one attendance item on the same patient, on the same day, the times of each attendance are noted here. 8 The name and provider number of the health professional who provided the service (the provider number used should be applicable to the practice location where the service was given). 9 The patient must sign and date the bulk bill voucher indicating their agreement to assign their right to Medicare benefits to the health professional. Note: It is a legal requirement that the voucher is signed by the patient only after the service has been provided and the form completed. A copy of the completed voucher must be given to the patient. PAGE 27 OF 55

28 Bulk bill headers manual processing The bulk bill headers you attach to your batches of vouchers must contain the information detailed in the example header below. Scroll over the highlighted numbers on the header for more information. References 1 Name and provider number of the health professional claiming or receiving payment of benefits (if different to the health professional providing the service). 2 The date that you are compiling the claim to send to Human Services. 3 The number of bulk bill vouchers in the claim. 4 The combined total of benefit for the bulk bill vouchers in the claim. 5 The bulk bill claim number. This can be an automatic computer generated claim number from within your practice management software or you can physically allocate the claim number if you are submitting your bulk bill claims manually. 6 Practitioner name, practice address and provider number for the health professional providing the service. 7 Signature of health professional providing the service. 8 Date, name and signature of witness to the signature of health professional who provided the service. Payment of bulk bill claims Payment is generally made via EFT. To receive payments via EFT, you must register your bank account details with Human Services. Payment times vary according to how you lodge your claims. The payment times indicated exclude bulk bill pathology services. Manual processing - usually paid after a minimum of 14 days from the date of lodgement. PAGE 28 OF 55

29 Medicare Online claiming - usually paid 2 to 3 working days from the date of lodgement. Medicare Easyclaim - usually paid within 24 hours from the date of lodgement. Note: the bulk billing method cannot be used to recover bad debts (penalties apply). References Register For assistance on registering bank account details for EFT payments, call the Medicare provider enquiry line on (call charges apply). Note: More information about the assignment of Medicare benefits can be found in the General Explanatory Notes of the MBS; in the Health Insurance Act 1973; or by calling the Medicare provider enquiry line on (call charges apply). Submitting bulk bill claims Manually submitted claims: Human Services will retain the Medicare copy of bulk bill claims. Medicare Easyclaim and Medicare Online: There is no requirement to retain paperwork in relation to bulk bill claims. Submitting manual bulk bill claims Attach one bulk bill header to the batch of bulk bill vouchers. You can include up to 99 bulk bill vouchers in each claim, though you are encouraged to submit bulk bill claims more frequently - for example, in batches of 50 bulk bill vouchers. You should send the paperwork to: GPO Box 9822 in your capital city. Alternatively, claiming paperwork can be taken into any Human Services office. Submitting bulk bill claims via Medicare Online or Medicare Easyclaim Medicare Online - are electronically batched and sent via your practice management software. Medicare Easyclaim - are sent individually via your EFTPOS terminal. PAGE 29 OF 55

30 Bulk bill stationery Health professionals wanting to manually bulk bill can obtain information on the required bulk bill stationery by calling the Medicare provider enquiry line on (call charges apply). Retaining bulk bill claims Manually submitted claims: Human Services will retain the Medicare copy of bulk bill claims. Medicare Easyclaim and Medicare Online: There is no requirement to retain paperwork in relation to bulk bill claims. Pa Note: From 1 September 2012, Human Services will no longer print bulk bill forms or accept orders for them. These forms will be available on our website. Providers will be able to print the blank form from the website, or complete the form electronically, print and mail it to Human Services. Instructions for completing and lodging forms will also be available on our website. PAGE 30 OF 55

31 Topic 3: Private billing and claiming Private billing There are two private billing account types: 1. paid account and 2. unpaid or partially paid account. Paid account - lodgement Claims for payment may be lodged: via Medicare Online (internet based) via Medicare Easyclaim (using existing EFTPOS terminal) by visiting a Human Services office by telephoning Human Services and outlining the details of the claim, then posting the paperwork to Human Services for assessment. Payment will be made via EFT or cheque by posting the paperwork to the at GPO Box 9822, in the applicable Capital City, for payment via EFT or cheque. Unpaid or partially paid account lodgement The options for unpaid or partially paid accounts are similar to those for paid accounts. Depending on the services your practice offers, the claim may be lodged: via Medicare Online (internet based) via Medicare Easyclaim (using existing EFTPOS terminal) via a drop box located in any Human Services office by telephoning Human Services and outlining the details of the claim, then posting the paperwork to Human Services for assessment. Payment will be made via cheque by posting the paperwork to the at GPO Box 9822, in the applicable Capital City, for payment via cheque. PAGE 31 OF 55

32 Unpaid or partially paid account lodgement Benefit payments for unpaid or partially paid accounts are posted to the claimant as a Medicare cheque, payable to you as the health professional who provided the service (or another person nominated by you). The claimant is responsible for forwarding the Medicare cheque to you, together with any outstanding payment. This method makes sure that claimants are involved in the payment process and can readily identify any shortfall (what they need to personally contribute) between the Medicare benefit and total charge. A Medicare cheque must be sent to the claimant (as it is a legal requirement) and cannot be sent directly to the health professional or practice under any circumstances. If claims are lodged manually, Medicare cheques are issued after a minimum of 16 days from the date of lodgement for GPs, nurse practitioners and midwives, and 18 days from the date of lodgement for other health professionals. Note: Generally Medicare cheques are issued two to three days earlier for claims lodged electronically. Private account requirements Where the doctor bills the patient for medical services rendered, the patient needs a properly itemised account/receipt to claim Medicare benefits. Under the provisions of the Health Insurance Act 1973 and Regulations, a Medicare benefit is not payable for a professional service unless it is recorded on the account setting out the fee for the service or on the receipt for the fee in respect of the service, the following particulars: What information is required for Medicare billing purposes? In addition to the details described in the document on the previous screen, where applicable, you will also need to provide the following information on private accounts where relevant: the times of each attendance where you wish to claim for more than one attendance item for the same patient, on the same day the name and provider number of the health professional claiming or receiving payment of benefits (if different to the service provider) an indication that a service was provided to a hospital in-patient. To signify inhospital treatment, insert the words 'admitted patient' or place an asterisk * against the item number or description of service. PAGE 32 OF 55

33 Inappropriate billing practices The following are examples of inappropriate billing practices. Including the cost of a non-clinically relevant service in a consultation charge. If a health professional chooses to use a procedure that is not generally accepted in their relevant profession as necessary for the treatment of the patient, the cost of this procedure cannot be included in the fee for an MBS item. Any charge for this procedure must be separately listed on the account and not billed to Medicare. Including an amount in the consultation charge for goods supplied for the patient's use at home (for example, wheelchairs, oxygen tanks, continence pads). The provision of goods for later use does not form part of the consultation and cannot be charged to Medicare. Charges can be levied for these items but must be separately listed on the account and not billed to Medicare. Charging part or all of an in-patient procedure to an MBS item number for an outpatient service. If a health professional charges part or all of an in-patient procedure against an MBS item number for an out-patient service, the account issued by the health professional is not an accurate statement of the services provided and would constitute a false or misleading statement. No Medicare benefits would be payable. Re-issuing modified accounts to include other charges and out-of-pocket expenses not previously included in the account. The account issued to a patient by a health professional must state the amount charged for a service provided and reflect what occurred between the patient and the health professional. Re-issuing an account to correct a genuine error is legitimate. However, if an account is re-issued to increase the fee or load additional components to the fee, the account is not a true statement of the fee charged for the service and would constitute a false or misleading statement. No Medicare benefits would be payable in respect of the services provided. PAGE 33 OF 55

34 Consequences of inappropriately issuing an account If the fee specified in an account includes components for goods and services that are not part of the specified MBS item: a Medicare benefit is not payable for the professional service the health professional who issued the account, or authorised it to be issued, will be guilty of making a false or misleading statement, which is a criminal offence under sections 128A and 128B of the Health Insurance Act Enforcement and recovery action Human Services has a legal responsibility and power to investigate health professionals suspected of making false or misleading statements, and can refer individual health professionals for prosecution if there is evidence of fraudulent activity. Excess Medicare benefits paid as a result of a false or misleading statement are recoverable from the health professional under section 129AC of the Health Insurance Act References List of bulk billing forms view list here Medicare stationery order form available online. PAGE 34 OF 55

35 Topic 4: Responsibilities for Billing Accuracy Responsibilities for Billing Accuracy As an eligible health professional, you are legally responsible for services billed under your provider number or in your name. You are responsible for incorrect claims regardless of who does the billing or receives the benefit. Legislation Accurate claiming of services under the MBS is a legal responsibility. Services lodged to Human Services for payment must be made in accordance with the legislative provisions: Health Insurance Act 1973 Health Insurance (General Medical Services Table) Regulation 2012 Health Insurance (Pathology Services Table) Regulation 2012 Health Insurance (Diagnostic Imaging Services Table) Regulation 2012 Note: For further information on the legislation visit the Comlaw website. Billing and claiming practices Important things to know... Your provider number uniquely identifies you and your practice location and can not be used by other health professionals to claim services. If services have been billed incorrectly under your provider number or in your name, you will be responsible for the repayment of benefits in excess of what should have been paid. Medicare only pays for services which are generally accepted by the majority of peers as medically necessary for the appropriate treatment of a patient. Even if the Medicare benefits that you claim go directly to a third party e.g. practice owner, you are still responsible for the repayment of incorrect benefits in excess of what should have been paid. You may be liable to pay an administrative penalty in addition to the repayment of incorrectly claimed services. PAGE 35 OF 55

36 Validating billing and claiming practices You are legally responsible for all services billed under your provider number or in your name. All services billed must fulfil the requirements in the MBS. The rules and item descriptors can be found on the MBS Online. If you are found to have incorrectly claimed benefits, you will be responsible for the repayment of benefits in excess of what should have been paid. Review your claiming practices to make sure that all relevant MBS requirements are met. Understand your current Medicare billing practices. Read the full item descriptor prior to billing to ensure selection of the correct item number. Regularly check your billing data to ensure the number and types of services billed are correct for the services that you provided. If you have any questions contact Check the MBS for item updates or amendments, for MBS updates go to MBS Online and Medicare s Forum. Incorrect Medicare payments Benefits paid in excess of what should have been paid to health professionals are considered a debt owed to the Commonwealth. Human Services is legally obliged to recover these debts in accordance with the Public Governance, Performance and Accountability Act Administrative penalties may also apply in the event of a compliance audit. If you are aware of incorrect Medicare payments, advise Human Services as soon as possible, by completing a Voluntary Acknowledgement of Incorrect Payments form. Early advice of incorrect payments may reduce any applicable administrative penalty. For more information View the administrative and civil penalties fact sheet. View the Human Services National Compliance program for more information. PAGE 36 OF 55

37 On Screen Link Reference Early advice If you become aware of an incorrect payment you have received from Medicare and you let us know voluntarily, you may avoid an administrative penalty. Consequences of non compliance Health professionals who are audited and found to be non-compliant with the requirements of the MBS: will be responsible for the repayment of benefits in excess of what should have been paid, and may be required to pay an administrative penalty. Health professionals who are reviewed under the Practitioner Review Program may be referred to the Director of Professional Services Review and as a result may be disqualified from billing under Medicare for a determined period. Health professionals who are investigated and suspected of possible fraud against Medicare may be referred to the Commonwealth Director of Public Prosecution for consideration of criminal prosecution. On Screen Link References Human Services Compliance Audit Human Services conducts compliance audits with health professionals and general practices to verify details of services where there is a risk that payments are incorrect. Increased Medicare Compliance Audits (IMCA) The Health Insurance Amendment (Compliance) Act 2011 introduced new laws that relate to the services rendered on or after 9 April There are now changes to obligations and procedures for Medicare compliance audits for incorrect payments and unsubstantiated services. Practitioner Review Program This program reviews the activities of health practitioners whose MBS claiming and/or PBS prescribing data indicate they may be engaged in inappropriate practice. More information can be found here. Referral to the Director of Professional Services Review This is an independent agency that may undertake a further review of services by a health professional. More information can be found here. Note: More information about the Increased Medicare Compliance Audits can be found on the Human Services website. PAGE 37 OF 55

38 Which of the following statements are true? You must fulfil all of the requirements of the MBS before you can bill an item under Medicare. Your provider number cannot be used to claim services performed by another health professional. Health professionals who are audited and found to be non-compliant with the requirements of the MBS will be required to repay excess benefits and may also be required to pay an administrative penalty. Medicare only pays for services which are generally accepted by the majority of peers as medically necessary for the appropriate treatment of a patient. If your practice staff claim the wrong item number under your provider number or in your name, you are not responsible. Correct Answer: All of the above are true except for the last. The last statement should read: If your practice staff claim the wrong item number under your provider number or in your name, you are responsible. Scenario: Services billed on your behalf The practice staff bill consultation items for you and choose attendance items according to the time the patient spends in the consulting room. They determine the time from when the patient first goes into the consulting room and when they return to the front desk at the conclusion of the consultation. As a result staff may be billing attendance items incorrectly. Are you responsible for the repayment of incorrectly claimed benefits, regardless of who does the billing or receives the benefit? Yes No Correct answer is: Yes Where MBS services have been billed incorrectly under your provider number or in your name, you will be responsible for the repayment of benefits in excess of what should have been paid, even if you only received a percentage of your MBS billing from your practice. PAGE 38 OF 55

39 Scenario: Payment of Administrative Penalties During a compliance audit it is discovered that you have incorrectly claimed item As a result you are required to reimburse Human Services for these services. Is it possible to avoid an administrative penalty? Yes No On Screen Link Reference PREMALIGNANT SKIN LESIONS (including solar keratoses), treatment of, by ablative technique (10 or more lesions). Correct answer is: No Where Human Services contacts you about your claims and you voluntarily tell us about any incorrectly claimed MBS services, the penalty may be reduced but not waived. You will not have to pay an administrative penalty if you voluntarily inform Human Services about incorrectly claimed MBS services before you are contacted about your claims. PAGE 39 OF 55

40 Topic: Summary Summary In this module you have covered the following: the two different billing methods that you can use when submitting claims to Human Services: 1 bulk billing or 2 Private billing the different claiming options that can be used for either method the information that is required on Medicare accounts/receipts, bulk bill vouchers and bulk bill headers and that you are responsible for all information provided the requirements for keeping adequate and contemporaneous records for Medicare purposes Medicare benefits paid inappropriately or incorrectly are recoverable in accordance with Section 129AC of the Health Insurance Act use of your provider number your legal responsibilities when billing under Medicare correct use of the MBS the consequences of not complying with the requirements of the MBS PAGE 40 OF 55

41 Module 4 Referrals and Requests This module explains the difference between referrals and requests. It also outlines what constitutes a valid referral and request for Medicare purposes. Topic 1: Referrals What is a referral? A referral is a letter or note to a specialist or consultant physician that may ask them to: further investigate, provide an opinion, treat and/or manage your patient or perform specific examinations, tests or procedures. A referral may result in the following: your patient has a single consultation only with the specialist or consultant physician your patient consults with the specialist or consultant physician more often (as determined by the referral) you liaise with the specialist or consultant physician. Some services provided by specialists and consultant physicians only attract Medicare benefits following the receipt of a valid referral. Note: Referrals may also be made to allied health professionals under specified Medicare initiatives. For more information refer to Category 8 at What constitutes a valid referral? Before a valid referral to a specialist or consultant physician is made: you must have undertaken a professional attendance with the patient and considered the need for the referral. You must be able to communicate the relevant information about your patient to the specialist or consultant physician (this does not necessarily mean an attendance on the occasion of the referral) the referral must be in writing by way of a letter or note and signed and dated by you the specialist or consultant physician must receive the written referral on, or prior to, the occasion of the professional service to which the referral relates. PAGE 41 OF 55

42 References On, or prior to Exceptions to this requirement are: a. a pre-anaesthesia consultation by a specialist anaesthetist (items ); b. a referral generated during an episode of hospital treatment, for a privately insured service provided or arranged by that hospital, where the hospital records provide evidence of a referral (including the referring practitioner's signature); or - an emergency where the referring practitioner or the specialist or the consultant physician was of the opinion that the service be rendered as quickly as possible; and c. where a written referral was completed by a referring practitioner but was lost, stolen or destroyed. Who can refer? A referral is valid when it is made to: a specialist by: another medical practitioner a registered dental practitioner (if arising from a dental service) a registered optometrist (if referring to an ophthalmologist) a nurse practitioner a midwife a consultant physician by: another medical practitioner an approved dental practitioner (if arising from a dental service) a nurse practitioner a midwife Duration of referral Referrals are valid for the period you specify in the referral letter and commence from the date of the first attendance with the specialist or consultant physician, not from the date the referral was written. Example: A patient is referred by their general practitioner (GP) to a specialist on 1 April 2012 for a period of 12 months. The patient's first appointment with the specialist occurs on 15 April For Medicare purposes the 12 month referral becomes active on 15 April 2012 and will remain valid for 12 months, until 14 April PAGE 42 OF 55

43 When issuing the account, the specialist must record the date the referral was actually written. In the above example, the date of referral is 1 April References period If you work in general practice, the referral is valid for 12 months unless you specify otherwise (for example, '3', '6', or '18' months or 'indefinitely' where clinically relevant). Note: Cross-referrals between specialists and/or consultant physicians can also occur and these are generally valid for '3' months. PAGE 43 OF 55

44 Topic 2: Requests What is a diagnostic imaging request? A diagnostic imaging request is a written request asking diagnostic imaging specialists to perform specified investigations or tests on your patient and report the findings back to you. Before you write a diagnostic imaging request, you must consider its clinical relevance and determine that the service is medically necessary for your patient. References clinical relevance A clinically relevant service is a service that is generally accepted in your profession as being necessary for the appropriate treatment of the patient. Note: There may be limitations on the type of diagnostic services that can be requested. For information on who may request a diagnostic imaging service, refer to Category 5 of the MBS. Diagnostic imaging form of request Requests for diagnostic imaging services do not have to be in any particular form. However, they must be in writing and contain sufficient information to clearly identify the item/s of service requested. This includes, where relevant, noting on the request the clinical indication/s for the requested service. You may use a single request to order a number of diagnostic imaging services. All services provided under this request must be completed within seven days of the first service being rendered. When you write a request for diagnostic imaging services, the following information must be included: name and address of your patient your name and address or name and provider number for the location where the request was written sufficient information to clearly identify the MBS item number/s of the service/s you are requesting your signature and the date of the request. You do not need to address your written request to a particular health professional. What is a pathology request? PAGE 44 OF 55

45 A pathology request asks an Approved Pathology Authority (APA) or an Approved Pathology Practitioner (APP) to perform specified tests on your patient and report the findings back to you. Before you make a pathology request, you must consider its clinical relevance and determine that the service is medically necessary for your patient. Health professionals who may request pathology tests which attract a Medicare benefit are: medical practitioners dental practitioners nurse practitioners midwives On screen link references - clinical relevance A clinically relevant service is a service that is generally accepted in your profession as being necessary for the appropriate treatment of the patient. Note: There may be limitations on the type of pathology tests that can be requested. You should contact the Medicare provider enquiry line on for assistance (call charges apply). Pathology services form of request You may request pathology service/s either verbally or in writing. Written requests do not have to be in any particular form. Verbal requests must be confirmed in writing within 14 days from the day you make the request. When you write a request for pathology services, the following information must be included: name and address of your patient your surname, initials of given names, practice address and provider number sufficient information to clearly identify the MBS item number/s of the service/s you are requesting your signature and the date of the request details of the hospital status of your patient (for example, were they or will they be an in-patient or out-patient at the time of the service and when the specimen is obtained) details of the person the request is directed to. A pathology request can be directed to either an APA and/or an APP. - If the request is directed to an APA, the form must show the full name and address of the APA. - If the request is directed to an APP, the form must show the surname, initials or given names and place of practice of the APP who the request is addressed to. Note: Any pathology request forms and combined pathology request/offer to assign forms prepared and distributed by pathologists to you must be in accordance with the approved form. PAGE 45 OF 55

46 Topic: References and Summary References The MBS is available at Who may request a diagnostic imaging service? Pathology request and combined pathology request/offer to assign forms Referrals to allied health professionals mbsonline.gov.au refer Category 5 of the MBS Online information on approved forms. refer Category 8 at MBS Online Summary In this module you have covered the following: a referral asks a specialist or consultant physician to investigate, manage and treat a particular medical condition a request asks for a specific service to be performed (for example, an x-ray or blood test) a referral must be received by the specialist or consultant physician before or at the initial attendance there are information requirements when issuing referrals and requests. Referrals and requests: provide your patients with access to specialist services are only valid after you have had a personal attendance with the patient and determined a clinical need must be in writing. PAGE 46 OF 55

47 Module 5 New Health Professionals Test your knowledge This module contains a range of knowledge checks and scenario based questions designed to check your understanding of MBS Primary Care items. Topic 1: Test your knowledge Question 1 Which of the following statements are correct? All visitors to Australia can enrol in Medicare To access Medicare benefits for eligible services, health professionals must register with Human Services. Residents of Norfolk Island are eligible for Medicare Human Services administers a range of health programs on behalf of the Australian Government Human Services delivers a range of health related payments and services to the Australian community The correct answer is: To access Medicare benefits for eligible services, health professionals must register with Human Services. Human Services administers a range of health programs on behalf of the Australian Government Human Services delivers a range of health related payments and services to the Australian community PAGE 47 OF 55

48 Question 2 True or False? Medicare cards issued by Human Services identify if a patient is eligible for Medicare benefits. The correct answer is: TRUE Question 3 Match the highlighted elements on the Medicare card to the correct description in the table. The correct answer is: Card issue number identifies the latest issue number for the Medicare card 02/2017 Expiry indicates the end date of this card issue John A Citizen Name of the person 1 Reference number identifies the individual named on the card Question 4 True or False? One provider number may be used in multiple practice locations, provided they are located within the same state or territory. The correct answer is: FALSE PAGE 48 OF 55

49 Question 5 True or False? Only persons who are eligible Australian residents or applicants for permanent residency are able to access Medicare benefits. The correct answer is: FALSE Question 6 True or False? Where you provide a service that you know is not eligible for a Medicare benefit - e.g. a medical examination to compete in kickboxing, you must advise the patient in advance that the service will not attract a Medicare benefit. The correct answer is: TRUE Question 7 Select the two correct statement(s) regarding provider numbers. A provider number uniquely identifies a health professional AND the location of the medical practice. As a health professional you do not need a provider number to access Medicare benefits for the services you provide A provider number is used to determine whether your services attract Medicare benefits at particular practice locations or all locations The correct answer is A provider number uniquely identifies a health professional AND the location of the medical practice. A provider number is used to determine whether your services attract Medicare benefits at particular practice locations or all locations PAGE 49 OF 55

50 Question 8 Select the correct statement(s) regarding Medicare coverage for treatment. Free treatment as a public patient in a public hospital. Free treatment as a private patient in a private hospital. Free or subsidised treatment by health professionals. The correct answer is Free or subsidised treatment by health professionals. Free treatment as a public patient in a public hospital. Question 9 Match the service description to the associated rebate percentage of the Medicare schedule fee. Private in-patient services in a private or public hospital 85% Out-patient GP attendance based services 75% Allied health services 100% The correct answer is Private in-patient services in a private or public hospital 75% Out-patient GP attendance based services 100% Allied health services 85% PAGE 50 OF 55

51 Question 10 When using MBS Online, which step is used to identify the correct item for a professional service you have provided? Enter a keyword in the search facility to locate a range of items appropriate for the service you have provided. Read the item descriptor for each item within the range. Read any explanatory notes for each item descriptor. All of the above. The correct answer is All of the above Question 11 Only one of the following services is eligible for Medicare benefits. Select the eligible service. An eye examination for the purpose of obtaining a pilot's licence. An examination on your own patient, to check on and provide advice on their general health. Writing a report for one of your patients for life insurance purposes. Services where the expense is the responsibility of the patient's employer. Telephone consultations. Surgical removal of a tattoo. The correct answer is An examination on your own patient, to check on and provide advice on their general health. PAGE 51 OF 55

52 Question 12 True or False? You have just spent 25 minutes performing a service that is not eligible for a Medicare benefit. Are you able to issue an account to your patient? The correct answer is TRUE Question 13 True or False? The MBS is a listing of all services health professionals can render in Australia The correct answer is FALSE Question 14 From the list below, select the four key requirements that must be met before a service you provide is eligible for Medicare benefits. Service is listed in the MBS Service is clinically relevant Service is provided at your practice You are eligible to attract benefits for the service provided Your patient is eligible for benefits The correct answer is Service is listed in the MBS Service is clinically relevant You are eligible to attract benefits for the service provided Your patient is eligible for benefits PAGE 52 OF 55

53 Question 15 Only one of the following statements regarding billing and claiming are correct. Select that statement. Where a patient has not paid their private account, health professionals may lodge a bulk billing claim to at least recover the Medicare benefit. Medicare cheques for unpaid account can be sent directly to the health professional where the patient gives their consent. Payment for paper-based bulk bill claims is generally made within 5 working days. A co-payment (e.g. $10 for bandages) may be charged in addition to the bulk billing of a claim, provided the patient does not hold a concession card or is under 16. Payment for bulk bill claims using one of Human Services' online claiming channels is generally made within 1-3 working days. The correct answer is Payment for bulk bill claims using one of Human Services' online claiming channels is generally made within 1-3 working days. Question 16 True or False? You are able to bill Medicare for goods supplied for the patient's use at home. The correct answer is FALSE Question 17 Only one of the statements below is correct. Select that statement. It is acceptable for a health practitioner to sign bulk billing vouchers on behalf of their patients where they have forgotten to do so, provided there are clinical records to support the service. A six month time limit applies to the lodgement of bulk bill claims. I can lodge private claims/invoices on behalf of my patient with their consent. The correct answer is I can lodge private claims/invoices on behalf of my patient with their consent. PAGE 53 OF 55

54 Question 18 True or False? To ensure your patient is able to claim the highest Medicare benefit possible, it is appropriate to charge part of an in-patient MBS item number for an out-patient service. The correct answer is FALSE Question 19 Unless otherwise stated, referrals from general practitioners are valid for: 12 months Three months 36 months 18 months The correct answer is 12 months Question 20 True or False? For Medicare purposes, all health professionals can request pathology services. The correct answer is FALSE Question 21 True or False? Pathology services can be requested verbally. The correct answer is TRUE Question 22 True or False? Pathology requests can only be directed to an Approved Pathology Authority. The correct answer is TRUE PAGE 54 OF 55

55 Question 23 From the list below, select the four pieces of information you must include on a request for a diagnostic imaging service. Patient's details - e.g. name and date of birth Name of the diagnostic imaging specialist who will be performing the service Description of the requested diagnostic imaging service Your name and address or name and provider number for the place of practice that the request originated from. Your signature and date of the request The correct answer is Patient's details - e.g. name and date of birth Description of the requested diagnostic imaging service Your name and address or name and provider number for the place of practice that the request originated from. Your signature and date of the request PAGE 55 OF 55