Dear Doctors and Health Care Workers
An important question about the supervision rules and their application in public hospitals today as well as a clarification about claiming if called about a patient, but not by a patient. Also, a good question about the likelihood of continuing telehealth post Covid.
Here’s the answers.
1. We are a public hospital. Our renal consultants are currently doing phone consults with their patients and have asked if the registrar does the phone call to the patient and then the consultant joins the call for the last 10 minutes can they still bill for that phone call?
This is an important question involving the supervision arrangements, which I believe occupy a podium winning position as some of the most opaque and confusing parts of Medicare’s chamber of secrets. This requires detail, so will not be brief…sorry in advance!
Considerations are firstly the law, then Medicare’s interpretation of the law and finally any relevant provisions of the National Health Reform Agreement (NHRA).
First – the supervision arrangements are regulated in the Health Insurance (General Medical Services Table) Regulations (No. 1) 2020.
Reg 1.2.11 lists all services able to be provided by someone ‘other than medical practitioners’ and includes common things like blood transfusions, ECGs and most of the chemotherapy items, but not consultations. Therefore, the starting point is that consultations cannot be supervised – your specialists have to attend the patient personally to claim. Then,
Second – we step back a few regulations to reg 1.2.7, which deals with consultation items. It basically confirms that consultations cannot be supervised when provided by a medical practitioner employed in a public hospital, because personal attendance is required. As I said, this is not easy to interpret. Here it is copied below so you can read it yourself.
“1.2.7 Personal attendance by medical practitioners—application and matters included
(1) Use this clause for items 3 to 723, 732, 900 to 6016, 6018 to 6024, 6028, 6051 to 6058, 6062, 6063, 10801 to 10816, 11012 to 11021, 11304, 11600, 11627, 11701, 11722, 11724, 11728, 11820, 11823, 11921, 12000, 12003, 12004, 12201, 13030 to 13104, 13106 to 13110, 13209, 13210, 13290 to 13700, 13815 to 13899, 14100 to 14124, 14203 to 14212, 14224, 14255 to 14288, 15600, 16003 to 16512, 16515 to 51318 and 90020 to 90096.
(2) The item applies to a service provided during a personal attendance by:
(a) a medical practitioner (other than a medical practitioner employed by the proprietor of a hospital that is not a private hospital); or
(b) a medical practitioner who:
(i) is employed by the proprietor of a hospital that is not a private hospital; and
(ii) provides the service otherwise than in the course of employment by that proprietor.
(3) Subclause (2) applies whether or not another person provides essential assistance to the medical practitioner in accordance with accepted medical practice.”
INTERPRETATION OF THE LAW ON MBS ONLINE
Here is Medicare’s interpretation of reg 1.2.7 – relevant sections of GN.12.30 copied below with key content underlined.
“Professional services which attract Medicare benefits include medical services rendered by or “on behalf of” a medical practitioner. The latter include services where a part of the service is performed by a technician employed by or, in accordance with accepted medical practice, acting under the supervision of the medical practitioner.
The following medical services will attract benefits only if they have been personally performed by a medical practitioner on not more than one patient on the one occasion (i.e. two or more patients cannot be attended simultaneously, although patients may be seen consecutively), unless a group session is involved (i.e. Items 170‑172). The requirement of “personal performance” is met whether or not assistance is provided, according to accepted medical standards:-
(a) Category 1 (Professional Attendances) items except 170‑172, 342-346, 820-880, 6029–6042, 6064-6075; …
Medicare benefits are not payable for … any of the items listed in (a) … when the service is rendered by a medical practitioner employed by the proprietor of a hospital (not being a private hospital), except where the practitioner is exercising their right of private practice, or is performing a medical service outside the hospital. For example, benefits are not paid when a hospital intern or registrar performs a service at the request of a staff specialist or visiting medical officer.”
INTERPRETATION OF THE LAW ON THE DEPARTMENT OF HEALTH WEBSITE
The DoH website reinforces the requirement that Medicare benefits are only payable in public hospital outpatient departments when an employed staff specialist is exercising a RoPP and the patient has elected to be private (i.e. has been asked to consent to being bulk billed and has agreed and signed the DB4) and there is a valid referral. The below link provides relevant content.
RELEVANT PROVISIONS OF THE NHRA
Business Rule G19 completely contradicts Medicare and requires that to be valid, an outpatient referral (but not an inpatient referral – go figure!) must name a specialist. Here it is:
“G19. An eligible patient presenting at a public hospital outpatient department will be treated free of charge as a public patient unless:
- there is a third party payment arrangement with the hospital or the State or Territory to pay for such services; or
- the patient has been referred to a named medical specialist who is exercising a right of private practice and the patient chooses to be treated as a private patient.”
MAKING SENSE OF IT ALL
So, now let’s pull it all together:
- As a general rule, consultations require personal attendance. For the Covid items ‘personal attendance’ is satisfied by continuous contact between the doctor and patient either by phone or video.
- Specialists employed by public hospitals can bulk bill public outpatients pursuant to the provisions of the NHRA only while exercising a RoPP, and when certain other criteria are met.
- To exercise a RoPP in a public hospital the doctor has to be employed – has to be able to show a signed RoPP Agreement. So, this excludes all VMOs who are not employees, but are contractors and therefore by definition cannot ‘exercise a RoPP’.
- Even if the doctor is an employed staff specialist exercising an RoPP she still has to personally attend the patient. She cannot and must not bill if the registrar exclusively provided the service.
- Best advice is to view the registrar’s contribution as superfluous to Medicare requirements. Meaning it is great that the registrar is able to attend and assess the patient, but her contribution has nothing to do with Medicare billing.
- The specialists (in your case renal physicians) should therefore satisfy themselves that the 10 minutes you have described as being their contribution meets ALL of the requirements of the Covid consultation item they intend to bill. So, for example, let’s say the registrar spends 10 minutes with a patient for a follow up consult and the consultant spends another 10 minutes. This would not justify the claiming of item 133 Covid equivalent items (20 minute complex consult) because the consultant only spent 10 minutes with the patient, so item 116 equivalents should instead be claimed.
- And of course, it goes without saying that you must keep adequate and contemporaneous records as they are always your first line defence in an audit. The records should be written by the consultant (not just the registrar) evidencing the consultant’s provision of the claimed Medicare service.
2. I am a GP.
a) Can we bill GP telephone consult item numbers like 91809, 91810 when called by residential aged care regarding a patient?
No. There are no Medicare rebates for talking to colleagues and other staff, whether you call them, or they call you. You can only claim these services if you meet all the requirements of the item description. The item description specifically requires a telehealth attendance between you and the patient, not between you and a nurse etc.
b) Are there any after-hours item numbers?
Yes. GPs can claim item 599 and 600 equivalents for urgent after-hours services, which are 92210, 92211, 92216 and 92217. Be careful claiming these items though. Determining ‘urgency’ is vexed and has been the subject of numerous investigations.
3. I have been using the COVID-19 telehealth item numbers for many patients, who live near the clinic and would not normally qualify for Telehealth. Patients are booking ahead their follow up appointments, and several still want telehealth. Is there any indication if these item numbers will be available after September?
Great to hear telehealth is working well for you and your patients and they are asking for more. Great work! Reports we are hearing are that patients just love it and there is no turning back.
However, at this stage the Covid telehealth items are legislated to automatically disappear at midnight on 30 September 2020, though Federal Health Minister, Greg Hunt, has announced he wants telehealth to continue after that date.
Continuance of telehealth is by no means certain though, and an unfortunate recent very public case of clear abuse of the new Covid telehealth items by a GP registrar has not helped the cause. You can read about it and the suggestions a colleague and I penned here if you are interested. The department has been understandably spooked, and it seems likely there will be restrictions of some sort moving forward, but let’s see.
Quite a long one tonight but we hope we have helped clarify a few very important issues.
Please keep the questions coming.
Margaret and the Synapse team.