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Attending After Hours - What Practitioners Should Know to Correctly Bill Medicare

Newsletter 01 November 2016

Over recent years home doctor services have increased in number and demand.  However, as patients become more interested in practitioners who attend after hours, so does Medicare.  

Medicare Benefits Schedule (MBS) item numbers applicable to after hours attendances cost more to the healthcare system than the average consultation with a general practitioner.  Accordingly, with the rise in the billing of after hours attendances, Medicare has put home doctor services and their practitioners under the microscope as part of its recent and ongoing review of these item numbers.  In particular, Medicare is auditing practitioners who bill high numbers of the MBS items applicable to “urgent” after hours services.  

With Medicare’s watchful eye, practitioners should be aware of the descriptors for after hours services to ensure they are billing the most appropriate and clinically relevant item, which may ultimately avoid  repayment to Medicare in the future.  We have, therefore, outlined six key points every practitioner should consider before billing Medicare for an after hours consultation.

1.The practitioner’s qualifications

To begin with, a practitioner needs to be aware of how their qualifications affect which MBS after hours item numbers are applicable.  It is common for practitioners from varying backgrounds and expertise to partake in home doctor services and/or attend to patients after hours.  However, what some may not be aware of is that Medicare distinguishes between those who are qualified or training general practitioners to other medical practitioners and they are classified according to Group A1 and Group A2, respectively.  We note that since the monetary benefit varies between the groups, incorrect billing due to a practitioner’s qualifications could result in repayment to Medicare.  For example, item 5023 is applicable for a standard after hours consultation at a patient’s home by a general practitioner, but item 5223 is to be used by other medical practitioners.

2. The location of the attendance

Medicare has divided after hours MBS item numbers according to the location of where the attendance is provided.  There are items applicable for an attendance in a practitioner’s consulting rooms, residential aged care facility and any other place which is not these venues or a hospital (i.e. a patient’s home).  We note that urgent after hours MBS item numbers do not distinguish between locations of the attendance.  However, the one condition is that if the attendance is performed at a consulting room, the practitioner must return to, and specifically open, the consulting rooms for the attendance.

3. The timing of the attendance

When billing, a practitioner must also consider what times are classified as “after hours”, as some MBS item numbers vary.  Generally, non-urgent after hours attendances at a patient’s home is considered before 8am or after 6pm on weekdays, before 8am or after 12pm on Saturday and all day on Sunday or public holidays.  There are some minor differences in the times if the attendance is in a consulting room.  Nevertheless, Medicare creates a sub-category known as “unsociable hours” applicable only to urgent attendances, which is any day from 11pm until 7am.

4. The length of the attendance

Many practitioners who regularly bill MBS item numbers would be familiar with Medicare’s practice to have item numbers specific to the length of the service.  This also applies when billing for after hours attendances.  After hours services are classified as brief, standard, long and prolonged. Again, medical practitioners should be aware of slight variations between the duration of a service provided by a qualified or training general practitioner and those provided by another medical practitioner.   

5. The number of patients attended to

It is not uncommon for practitioners to attend a home, aged care facility or their own consulting rooms after hours to discover that more than one patient requires their care.  These circumstances create an additional layer of complexity when considering what item to bill for which patient.  Most standard after hours item numbers allow a practitioner to bill for attendance on multiple patients on the one occasion.  However, the major exception is with regard to urgent after hours attendances as these items can only be used for the first patient.  For any subsequent patients attending on the same occasion standard after hours items apply.

6. The type of medical treatment provided

Whilst the above elements must be considered when billing after hours item numbers, Medicare’s current investigations and audits appear to be focused on the billing of urgent consultations.  Therefore, the confusion lies with the definition of “urgent”.  The only guidance provided for the MBS item descriptors for urgent after hours services (597, 599, 598 and 600) is that ‘the patient’s condition requires urgent medical treatment’.  However, this term has been elaborated further in the Health Insurance (General Medical Services Table) Regulation 2015.  To adhere to the regulations, when a practitioner considers which item to bill for an after hours attendance, they should ask themselves – could the medical treatment I provided in, or before, the after hours attendance be delayed until the start of the next in-hours period?  If the answer is yes, the medical treatment is not classified as urgent.  Not only has the new regulation attempted to define “urgent medical treatment”, it has also developed a test which Medicare can apply when determining the appropriateness of urgent after hours billing.  This test is both subjective and objective in that the treatment must be considered urgent by the attending practitioner and to the general body of medical practitioners.   

It is often the case that even medical practitioners, who always consider the six key points above, may be investigated by Medicare.  So what can a practitioner do to demonstrate to Medicare that they have billed the correct item numbers?  The only answer is to ensure that a patient’s medical records note the location of the service, the time of the attendance and ample detail of the care and treatment provided.  For practitioners involved with home doctor services, it is also useful to ensure records are kept of the patient’s initial request for an after hours attendance for further evidence of when, where, how and why the service is required.

John Petts, Partner



Newsletter 01 November 2016
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