The business of general practice: Medicare Q&A

Paul Hayes

9/11/2018 10:38:36 AM

GPs and practice owners recently had the opportunity to submit questions to the Department of Human Services regarding Medicare. Here are the answers.

GPs were very happy for the opportunity to submit questions regarding Medicare.
GPs were very happy for the opportunity to submit questions regarding Medicare.

The strong turnout and positive feedback for the RACGP’s inaugural Practice Owners National Conference, held in August, was evidence of a strong GP appetite for support and information about running and owning your own business.
The conference was designed to help fill GPs’ need for relevant business information, connect practice owners with their peers from across the country, and provide mentoring and assistance for GPs who are aspiring to become practice owners.
Attendees also had the opportunity to submit questions on notice to the Department of Human Services (DHS) regarding Medicare. Here are the answers to some of the most pertinent queries.
How do I determine if a condition is considered chronic when determining if my patient is eligible for chronic disease management services?
To be eligible to claim a chronic disease management (CDM) item, a patient must have a chronic or terminal medical condition that has been or is likely to be present for six months or longer.
Patient eligibility for a CDM service should be determined by a GP, using their clinical judgement and taking into account both the Medicare Benefits Schedule (MBS) eligibility criterion and general guidance.
Where a patient’s ‘condition’ would not obviously come within the MBS definition, a GP may still consider whether the patient’s condition and circumstances are such that they require a care plan because of factors such as non-compliance, inability to self-manage or functional disability.
Conditions such as substance misuse, smoking, obesity, unspecified chronic pain, and hypertension would not commonly be regarded as chronic medical conditions in themselves; however they may typically be regarded as risk factors for the development of chronic conditions.
Conditions such as these can occur across a wide spectrum of severity and in a broad range of circumstances. Where a patient has complications or comorbidities that may be a result of, or exacerbated by, such conditions or risk factors, and the patient is unable to self-manage or comply with care and treatment and is functionally disabled by their condition, it may make them eligible for CDM services.
In these cases, a GP should satisfy themselves that their peers would regard the provision of a CDM service as appropriate for that patient, given the patient’s needs and circumstances.
Can I raise a private account for an MBS item 10997 service on the same day that I have bulk billed a 721 GP management plan and 723 team care arrangement?
Yes, you can bill in this way.
Do note, however, that where the item 10997 service is performed on the same day as a 721 and 723, it must be clinically relevant and can only be performed for a patient once the GP management plan is in place.
If you do end up in this claiming situation, we would recommend that you let the Department of Human Services (DHS) know that the services were performed on separate occasions to assist the department in assessing your claim correctly.
How do I inform the Provider Benefits Integrity Division of incorrectly billed items?
If a medical professional has incorrectly claimed a benefit or received a payment from Medicare, it is important that they notify the Department of Health (DoH) using the voluntary acknowledgement form as soon as possible.
It is important to note that incorrect payments identified by a voluntary acknowledgement need to be repaid to the DoH.
When developing team care arrangements, what are the requirements around consultation with other health service providers?
To claim a team care arrangement (TCA) item, the team must include the patient’s GP and at least two persons who are providing different kinds of ongoing care to the patient and who have contributed to the plan.
The TCA should also refer to treatment and care to be administered by providers who are not contributing to the plan.
It is always important to check MBS online for current item requirements. 
As at 19 September 2018, when coordinating the development of TCAs, the GP must:

  • consult with at least two collaborating providers, each of whom will provide a different kind of treatment or service to the patient, and one of whom may be another medical practitioner, when making arrangements for the multidisciplinary care of the patient
  • prepare a document that describes 
    • treatment and service goals for the patient
    • treatment and services that collaborating providers will provide to the patient
    • actions to be taken by the patient
    • arrangements to review the preceding three points by a date specified in the document
  • explain to the patient and carer (if any, and if the practitioner considers it appropriate and the patient agrees) the steps involved in the development of the arrangements
  • discuss with the patient the collaborating providers who will contribute to the development of the TCAs, and provide treatment and services to the patient under those arrangements
  • record the patient’s agreement to the development of TCAs
  • give copies of the relevant parts of the document to the collaborating providers
  • offer a copy of the document to the patient and the carer (if any, and if the practitioner considers it appropriate and the patient agrees)
  • add a copy of the document to the patient’s medical records.
MBS item 723 cannot be billed until the TCA for the patient is finalised and in place.
Why is there a delay in receiving the Medicare benefit when I only charge my patient the out-of-pocket amount?
The DHS can only assign benefits according to legislation. The Health Insurance Act 1973 only allows a benefit to be paid directly to a practitioner when they bulk bill. 
If you only charge the gap amount for your patient, the benefit is eventually paid to you but it must first go via the claimant.
The legislation requires that payment of this type occur by cheque which, in addition to the payment having to go via the claimant, results in delays when compared to bulk billing.

Practice-owners-conference-Hero.jpgThe first ever RACGP Practice Owners National Conference received an enthusiastic response from GP attendees.
Are you able to bill patients to cover the cost of consumables used in plastering and suturing if you bulk bill for these procedures?
Under the Health Insurance Act 1973, a bulk-billing facility is available to people who are eligible for a benefit under the Medicare program. 
If a practitioner bulk bills for a service, the practitioner accepts the relevant Medicare benefit as full payment for the service.  
No additional charges for that service can be raised. This includes but is not limited to:
  • any consumables that would be reasonably necessary to perform the service, including bandages and/or dressings
  • record-keeping fees
  • a booking fee to be paid before each service
  • an annual administration or registration fee.
Where a practitioner provides a number of services (excluding operations) on a single occasion, they can choose to bulk bill some or all of those services and privately charge a fee for the other service (or services), in excess of the Medicare rebate.
The privately charged fee can only be charged in relation to the stated service (or services). Where two or more operations are provided on a single occasion, all services must be either bulk billed or privately charged.
Where a service is not bulk billed, a practitioner may privately raise an additional charge against a patient, such as for a consumable.  
An additional charge can also be raised where a practitioner does not bulk bill a patient but rather charges a fee that is equal to the rebate for the Medicare service.
For example, where a GP provides a professional service to which MBS item 23 relates, the practitioner could, in place of bulk billing the patient, charge the rebate for the service and then also raise an additional charge (such as for a consumable).
How do I bill for a re-excision of a malignant lesion when the removal of a further margin is clinically indicated? Are the any resources available to assist practitioners in relation to skin services?
For Medicare billing purposes, a re-excision of a further margin with curative intent is based on the original excision. If the original lesion was malignant, the basis for the further margin is also malignancy. You can bill the re-excision using the item you billed for the original excision.
The DHS has published an education guide on billing skin lesion excision and biopsy items that covers this topic.
Why does Medicare not increase with consumer price index?
The Government announced in the 2018–19 budget, under Guaranteeing Medicare, that the investment in Medicare would increase from $24 billion in 2017–18 to $28.8 billion in 2021–22.
This includes the Medicare rebate indexation, which was re-introduced in the 2017–18 budget as part of compacts with the Australian Medical Association (AMA) and the RACGP, which included their support for the MBS Review and My Health Record. The indexation will deliver an additional $1.5 billion in funding to Medicare services to 2021–22.
Medicare indexation will continue annually, on an ongoing basis, using the calculation which has formed the basis of indexation of MBS items by successive governments since 1995.
GPs are carrying more and more of the clinical burden of CDM, yet our Medicare rebates have not improved in years. Why are we so undervalued by the Government?
The Government supports Australians’ access to high-quality, timely and affordable healthcare by providing subsidies through the MBS.
Although the Government is responsible for setting the MBS fees and associated rebates, it has no authority to set the amount that GPs charge for their services. GPs are free to set their own value on their services, and the actual fee charged is a matter between GP and patient. All GPs have the facility to bulk bill and it is their individual decision whether they choose to do so.
To encourage GPs to bulk bill patients who may find it more difficult to pay a private fee, the Government provides additional incentives for services that are provided to Commonwealth Concession Card holders and children under 16 years of age. Currently, the incentives are set at $6.30 per bulk-billed service in metropolitan areas, and $9.50 per bulk-billed service in regional, rural and remote areas.
The indexation of Medicare rebates for standard GP consultation services resumed on 1 July 2018. The indexation of specialist GP services, such as health assessments and CDM services, will resume on 1 July 2020.
The most recent Medicare data (year-to-date July 2017 to March 2018) shows that bulk-billing rates continue to increase. The bulk-billing rate for un-referred GP attendances is 85.8%. The decision to provide bulk-billed services is a decision for GPs, who must weigh the business needs of the medical practice against their patient’s capacity to pay.
In making the decision to bulk bill a patient, the GP takes into account the business cost to the practice of the medical service, its value to the patient, and the convenience of accepting the MBS rebate, along with the bulk-billing incentive where applicable, as full payment for the service.
How do I look up whether my patient has already got a CDM or mental health treatment plan in place online?
The DHS provides two options for practitioner to check if a care plan item can be claimed for their patients.
The first option is viewing a patient's care plan history using Health Professional Online Services (HPOS). This function allows you to access specific information about any care plans items your patient is has been billed in the last 12 months, including the date they were provided.
You can only use the ‘view care plan history’ function if your patient is: 
  • over the age of 18
  • registered for Medicare online services
  • has given you their verbal consent to check their history.
Patients are able to see which practitioners have checked their care plan history, so we would recommend recording their consent at the time you check their care plan. 
The second option for checking whether a care plan item can be billed is the MBS item online checker function in HPOS. This function is more general-purpose and includes the checking of other non-care plan items, so it does not provide the specific available under the view care plan history function.
Can care plan item numbers be billed on the day after the consultation if the care plan was completed on that following day? Or can they only be billed on the day of attendance?
The date of service used for a care plan should be the date on which the attendance of the patient occurred in relation to the development of the plan. 
In situations where not all of the item requirements are completed on the day of the care plan attendance, the item cannot be billed to Medicare until this occurs.
For example, were a GP to provide a care plan attendance on a Monday, but not complete all the requirements of the item until the following Wednesday, the practice could bill the care plan item to Medicare from that Wednesday, but would list the Monday as the date the care plan service occurred.

department of human services MBS items Medicare medicare benefits schedule

newsGP weekly poll Have you noticed a shift in patient sentiment towards paying for general practice care?

newsGP weekly poll Have you noticed a shift in patient sentiment towards paying for general practice care?



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Mandy Harrison   10/12/2018 3:50:20 PM

May i have an electronic version of these articles from the first conference?
Thank you so much

newsGP   11/12/2018 3:28:30 PM

Thanks for your query, Mandy. The presentation are available on this year’s conference website ( Thank you.

lillian   12/04/2019 10:49:50 AM

item 721, is there a time frame for this item?, I know 12 months before claiming again. Got a rejection that the client was not ellible.

Ziggy Gillham   24/06/2019 6:46:12 PM

Once a team care arrangement has been completed by the doctor in the initial consult and it is forward to the other collaborating providers, can the 723 be billed on the day of the consult without direct acknowledgment from the other providers or can the 723 only be billed once acknowledgement of care from the collaborating providers has been received?

Kristy Stanford   13/10/2022 10:17:35 AM

Hi - Can you bill an item 10997 on the same day as a 23 etc