![]() His related to whether Medicare’s refusal to pay the claims was a legally reviewable decision because a written legal advice had indicated that GPs are legally classified as “specialists” under the Health Practitioner National Law, and therefore rule GN.5.15 in the MBS should apply, which would negate the coning rules. Mine were around how it was that GPs were legally able to staff the ED of a major teaching hospital in a capital city, and why pathology was being billed to Medicare in a public ED at all. Well before our first meeting, I had a long list of questions and so did the lawyer. Pathologists have to report on all tests, even though they will only be reimbursed for three. Coning is limited to tests ordered by GPs in the outpatient setting and the rules do not apply to admitted patients or for services requested by specialists. Basically, episode coning provides that when more than three tests are requested for a patient on the same day, by one or more GPs, Medicare benefits are paid for only the three most expensive items. What transpired was that the GPs who staffed their emergency department ordered most of the pathology, and Medicare was applying “episode coning” rules which caused many of the claims to bounce. For them, the issues were both how and whether to bill, and the affected doctors were nervous. The lost revenue was circa $1 million per annum. More recently, I was contacted by a senior lawyer, the general legal counsel of a major teaching hospital in a capital city concerning Medicare rejecting half of their pathology claims. When we talked through her situation, her options were a) breach Medicare requirements by billing for non-clinically relevant services, b) breach her contract with the hospital by not attending her patients daily, or c) attend her patients daily, not bill to Medicare, and not be paid. She therefore didn’t know when or whether to bill. ![]() However, she didn’t think this would always be necessary given the sub-acute setting. In another example, a physician explained to me that her service contract with a private hospital stipulated that she was required to do a ward round of her admitted patients daily. Her error did not relate to what to bill, but how to bill the one MBS item she had correctly chosen.Ĭomment Medicare: how it started, how it’s going She bulk-billed and charged a concurrent gap (though for different services), but it was found that the two were inextricably linked and she had committed a crime. In 2006 a GP was found guilty of 96 counts of criminal fraud for incorrectly billing only one MBS item, and there was no concern that the item number she chose was incorrect or that she had not provided the service she billed. Other times confusion can relate to how to bill, when to bill, and whether to bill, rather than just what to bill. So, if the test is performed on a patient complaining of chest pain but the pain turns out to be indigestion, which is not a serious or life-threatening abnormality, is the doctor guilty of an offence?īut it’s not always indecipherable drafting, as with item 11707, that causes billing confusion. Take the recently introduced ECG item 11707. It requires that the ECG “is reviewed in a clinically appropriate timeframe to identify potentially serious or life-threatening abnormalities”. MBS descriptions can border on the absurd. When a hospital’s general legal counsel can’t make head or tail of Medicare, what chance do the doctors have?
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