Preparing Medical Accounts for Patients

Bulk billing is when the practice bills Medicare directly for the services and/or treatment provided to the patients without incurring any out-of-pocket costs on the patient. In order to bulk bill, the patient must assign their right to a Medicare benefit to the practice, which Medicare will then pay the benefit directly to the practice. For health professionals that bulk bills, they accept the Medicare benefit as the full payment for services provided, i.e., they cannot make additional charges on top of the Medicare benefit. This includes additional fees such as recordkeeping fees or administrative charges (Services Australia, n.d.-b).

Depending on your workplace’s procedure, they may bill Medicare daily, weekly, or monthly. However, note that Medicare benefits have a time limit of two years, which means services that were provided more than two years earlier than the date the claim was lodged are not payable. This is also outlined in the Health Insurance Act 1973 (Services Australia, 2023).

There are a few different avenues to submit bulk bill claims, with the two commonly used ones being Medicare Online claiming and Medicare Easyclaim. Other claiming options include ECLIPSE and Medicare Bulk Bill Webclaim. You need to check with your supervisor which system your workplace uses, as different systems have different billing document requirements. You also need to familiarise yourself with the procedure set out by your workplace, to ensure that you prepare the medical account accurately to not hold up the claims process.

We will briefly look at the steps to submit bulk bill claims via Medicare Easyclaim, as outlined in the extract below.

There are 5 steps to submit bulk bill claims:

1. the patient's Medicare card is swiped through your EFTPOS terminal, or their details are stored in the integrated practice management software
2. claim details are entered via the keypad or using the details stored in the integrated practice management software. Short-cut keys can be used for provider IDs and common item numbers
3. the claim is sent to us for verification and an approval message is sent back to the terminal within seconds
4. the patient then presses a button on the keypad to assign their Medicare benefit to you. The EFTPOS terminal will then print a patient receipt
5. you receive a single payment into your nominated bank account in 2 to 3 working days. There is no need to batch or store claims

^{(Services Australia, 2021)}

After you lodge the bulk billing claims, you also need to ensure you recorded the appropriate information for documentation purposes. Your workplace will have a guideline on the information required to be documented and you should refer to it. It generally includes patient details, services provided by your workplace, the relevant MBS item code, and other relevant billing details.

Another important thing to note is that prior to submitting the claim to Medicare, you need to make sure that you have the correct Individual Reference Number (IRN). The IRN is a unique identifier located on the patient’s Medicare card and it should match the medical account and the services provided. It is part of your legal responsibility to ensure that the correct IRN is used, otherwise there may be legal consequences for both the health professional and the patient. According to Services Australia (n.d.-b), when a claim is submitted using an incorrect IRN, under the Health Insurance Act 1973, it is considered as making a false or misleading statement. The health professionals may need to repay the paid benefits and the patient’s future Medicare services may not be accepted due to this error.

The image below is a summarise information sheet developed by Services Australia (2022a).

The health professionals at your workplace may choose to set their own level of fees for the services they provide, and often above the Medicare benefit. This means that patients will have to pay an out-of-pocket cost. Depending on your workplace’s policy and procedures about private medical accounts, you may need to assist patients when they are paying their account. The extract below outlines the options available for a practice to issue private account by Services Australia:

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
   • lodges the account or receipt with us
   • waits for us to post a pay practitioner Medicare cheque
   • forwards the Medicare cheque to you to finalise the account
3. The patient claims from us using the unpaid account by
   • lodging the account with us
   • waiting for us to post a pay practitioner Medicare cheque
   • forwarding the Medicare cheque together with the difference between the cheque and account total to you

^{(Services Australia, n.d.-b)}

It is important that you clarify with your supervisor or practice manager how your workplace issues medical accounts to patients, if your workplace private bills patients. This is so that you can familiarise yourself with the procedures and prepare the appropriate medical accounts for patients accurately. Indeed, one of the vital steps you need to keep in mind is to provide the patient with a properly itemised account and/or receipt to facilitate claiming the Medicare benefits.

While it may be your patient’s responsibility to claim their benefits with Medicare, it is part of you and your workplace’s duty to provide them with a proper account and/or receipt. This is in line with the Health insurance Act 1973, whereby the service fee must be recorded accurately either in the account or on the receipt, in order for the Medicare benefits to be paid.

According to Services Australia (2022b), the following details should be included:

• the name of the patient
• the date of the service
• the amount charged
• the total amount paid
• any amount still owing
• an item number and/or a description to identify the service

Under section 51 of the Health Insurance Regulations 2018, you must include certain information on an account or receipt.

You can provide either or both:

• the name of the health professional that’s providing the service and address of the place of practice for the service
• the provider number of the health professional.

We can record more than one practice location for you. Always use the provider number for the practice location where you provide the services

^{(Services Australia, 2022b)}

Referred Patients

You need to check with your workplace whether there is a different procedure when billing referred patients. Generally, when preparing the medical account for a referred patient, you need to also include the following details (Services Australia, 2022b):

• the name of the referring health professional
• the address or provider number of the referring health professional
• the patient’s referral date
• the period the referral is valid for.

Non-Medicare rebate

As you learned earlier, not all services and/or treatments are eligible for Medicare treatment and will incur out-of-pocket cost for patients. You need to familiarise yourself with the services provided by your workplace, especially whether they are eligible for Medicare. Other than providing accurate advice to patients, it can assist you in preparing the appropriate account. In this case, you will private bill the patient and provide a receipt for them. Patients who have private health insurance may be able to make claims from their health insurer, therefore, you need to ensure that you prepare a properly itemised receipt for them. Note that your workplace may have their own set of policy and procedures on how to bill patients who received services that are ineligible for Medicare rebate.

Your workplace may provide services and/or treatments to patients who hold a Department of Veterans’ Affairs (DVA) Health Card. DVA offers a range of health services for veterans, war widows/widowers, and dependents to treatment or services that are clinically required. Services Australia, on behalf of DVA, makes payments for services provided by health professionals to DVA Health Card holders. Below are examples of how different DVA Health Cards look like.

There are four different card types (Services Australia, n.d.-a):

Gold & Gold T P I

Holders of Gold Cards are entitled to the full range of health care services at DVA’s expense including medical, dental, optical care and subsidised pharmaceuticals. They are also entitled to medical aids and appliances to assist them to manage their health conditions.

White

Holders of a White Card are only entitled to be treated at DVA’s expense, including subsidised pharmaceuticals, for their accepted service related disabilities or illnesses.

Orange

Holders of an Orange Card are entitled to subsidised pharmaceuticals only.

It is important to keep in mind that when you communicate with patients who wish to be treated as a DVA Health Card holder, you explain whether the required service is payable by DVA. According to Services Australia (n.d.-a), a service is payable when the

• the DVA Card Holder is entitled to DVA funded treatment
• you are registered as a provider and are eligible to receive a payment for the service provided
• the service is reasonably and clinically necessary

While your practice may have its own set of policy and procedure to prepare and process DVA claims, read the extract below for an outline of the general steps so you have a good understanding of the process.

Step 1

Ensure you are eligible to claim payments from DVA by checking the requirements described on Services Australia and DVA’s websites.

Select Notes for Providers and Fees schedules for more information.

Step 2

Obtain a provider number for each location from which you’ll provide services to DVA Health Card holders and register bank account details for each of your locations with us.

Step 3

If you are unsure of an entitled person’s eligibility for treatment or the extent of what is covered for a Health Card holder, contact DVA for information.

Step 4

Read the Notes for Providers and relevant fees schedules to ensure the service you will provide the DVA Health Card holder attracts a DVA benefit.

Select Notes for Providers and Fees schedules for more information.

Step 5

If you intend to claim items that attract G S T, ensure you have notified us of your Australian Business Number, A B N, and G S T status.

Refer to the DVA G S T information on our website.

Step 6

Contact DVA before providing a service if it requires prior approval.

Step 7

Comply with DVA’s business rules governing the provision of services and requirements for referrals, requests and document retention.

Select Notes for Providers and Fees schedules for more information.

Step 8

Submit your claim for payment via your chosen lodgement method, refer to DVA Claiming Channels module.

Select Notes for providers and Fees schedules for more information.

^{(Services Australia, n.d.-a)}

There are three different digital claiming options to prepare medical accounts for DVA claims (Services Australia, n.d.-a):

• DVA Webclaim: internet-based, real-time channel to submit claims securely through Health Professional Online Services (HPOS).
• Medicare Online: can be integrated with your workplace’s management software to submit claims online.
• In Hospital Claims (IHC): an extension of Medicare Online used by hospitals and day procedure centres.

As you can tell, there are multiple channels to submit claims from DVA, and it is unrealistic for us to go through the steps for each channel in this Study Guide. Hence, it is extremely important that if your workplace is eligible to provide DVA services, you learn and understand the procedures required to submit DVA claims.

Workers’ compensation is a compulsory insurance that most employers are required to take out. This type of insurance ensures employees are compensated when they need medical treatment, rehabilitation, or time off to recover after being injured at work. If an employee gets sick from work, the relevant costs are also covered. Premiums of this insurance scheme are paid by the employer and cover most workers. There are 11 workers’ compensation schemes, with three for those who are employees of the Commonwealth Government and eight other schemes for employees in different states and territory (Healthdirect, 2021). You can click on each state or territory to learn more about your jurisdiction’s workers’ compensation legislation:

• NTWorkSafe
• ReturnToWorkSA
• SafeWork NSW
• WorkSafe ACT
• WorkCover Queensland
• Worksafe Tasmania
• WorkCover WA
• Worksafe Victoria

When providing services for patients who wish to claim workers’ compensation, you need to check whether the injury or illness is worker-related. Otherwise, they may not be eligible for workers’ compensation. Generally, you will prepare accounts in a similar way as you would for a private patient. However, you would need to make sure that the health professional provided an injury report (or any other relevant supporting documents) to the patient, along with the itemised receipt. The patient will then lodge for claims with their respective insurance scheme. Depending on the state and territory you are in, there may be different procedures to process workers’ compensation accounts. Therefore, you need to be familiar with your workplace’s policy and procedures, otherwise it may affect the patient’s claims process.

When scheduling an appointment, the patient may inform you that they wish to receive treatments and claim the service and/or treatment fees of an injury due to a motor accident (or transport accident). You need to obtain the necessary information from the patient before proceeding, including the insurance provider, claim number, policy details, and contact information. You also need to verify the liability, whereby the patient can make claims against the at-fault party and their insurer. Depending on your workplace’s policy and procedure, there may be additional forms and information that you need to gather and verify before scheduling an appointment for the patient.

In terms of preparing accounts, you need to familiarise yourself with the billing requirements of different third-party insurance providers. The at-fault insurer provider is required to pay for treatment and care for the injured party. The services provided must be deemed reasonable and necessary in order for the claim to be payable, and can vary from case to case. Therefore, insurance providers would need relevant medical information to determine whether the services rendered are reasonable and necessary (NSW Government, n.d.). Hence, it is vital that you clarify this with your supervisor and understand the procedures to handle accounts relevant to motor vehicle third party claims, including the appropriate documentation (e.g., reports, test results, and clinical notes). Otherwise, your patient may be refused the claim due to insufficient or incorrect documentation. Note that different states and territories may have different procedures and it is part of your responsibility to clarify this with your workplace.

In this section, you were introduced to two main billing account types: bulk billing and private billing, including the procedures to prepare for these accounts.

You also learned about preparing accounts that involved items that are not eligible for Medicare benefits. You also learned about other account types that you may come across at your workplace, such as DVA claims, workers’ compensation claims, as well as transport accident claims.

Healthdirect. (2021, October). Workers’ compensation. https://www.healthdirect.gov.au/workers-compensation

New South Wales Government. (n.d.). Invoicing information for NSW Health doctors. https://www.servicesaustralia.gov.au/referring-and-requesting-medicare-services-for-health-professionals?context=20

Services Australia. (n.d.-a). Department of Veterans’ Affairs (DVA). https://hpe.servicesaustralia.gov.au/department-of-veterans--affairs.html

Services Australia. (n.d.-b). Medicare Benefits Schedule (MBS). https://hpe.servicesaustralia.gov.au/medicare-benefits-schedule.html

Services Australia. (2021, December 10). Bulk bill claims. https://www.servicesaustralia.gov.au/medicare-easyclaim-bulk-bill-claims?context=22881

Services Australia. (2022a, August). How to submit Medicare bulk bill webclaims. https://hpe.servicesaustralia.gov.au/INFO/HPOS/HPOSM10INFO1.pdf

Services Australia. (2022b, March 3). Private billing procedures for health professionals. https://www.servicesaustralia.gov.au/private-billing-procedures-for-health-professionals?context=20

Services Australia. (2023, January 9). Bulk bill payments to health professionals. https://www.servicesaustralia.gov.au/bulk-bill-payments-to-health-professionals?context=20#a7

Walshs. (2022). [Photograph of someone using a calculator with a stethoscope beside them.] https://walshs.com.au/medical-accounting/