What is the Medicare Benefits Schedule (MBS)?
The Dept of Health defines the MBS as ‘a list of health professional services subsidised by the Australian Government. There are over 5,700 MBS items which provide patient benefits for a wide range of services including consultations, diagnostic tests and operations.’
Basically, it is a list of codes that tells you what you’re allowed to bill Medicare for, based on the consult you’ve had.
How do I know if I’m billing correctly and is there training provided?
You should read through the MBS located here to get an idea of the items, rules and restrictions around billing: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Home
You can also send through an enquiry to the AskMBS team but it is important to note that their word isn’t an authority. When asked, the AskMBS team have advised that “AskMBS provides interpretation and application of the Medicare Benefits Schedule (MBS) and associated legislation and regulations. Whilst the service works to provide accurate information about Medicare billing, it is up to individual practitioners to satisfy themselves that the service rendered meets the requirements of the MBS item descriptor. This includes the application of clinical judgement to determine whether the services were clinically relevant, that is, generally accepted by the relevant profession as necessary for the appropriate treatment of the patient.
It is important to note that guidance provided by the AskMBS Advice Service is not considered definitive legal advice, and health professionals are encouraged to seek independent counsel. Medicare billing advice provided by the service is prepared in response to the specific circumstances given in each individual enquiry. It is not general billing guidance and therefore it is unsuitable for application to other billing situations or scenarios.”
There are various training courses and guidelines now available to help you understand how to bill your Medicare Provider Numbers.
We’ve included a few training courses you can look into below:
Department of Human Services
The Department of Human Services have released training guidelines and e-learning activities to help GPs understand how to claim MBS items appropriately with specific medical conditions. These guidelines include training for billing mental health care, multiple MBS items, chronic disease GP management plans and more. To have a look at the various resources available, you can go to MBS education for health professionals at this link – https://www.humanservices.gov.au/organisations/health-professionals/subjects/mbs-education-health-professionals
The Department of Health also has resources available to help ensure you comply with health payment requirements. You can have a look over this information at this link: https://www.health.gov.au/internet/main/publishing.nsf/Content/health-compliance
MBS items Online Checker
The MBS items checker is available through Health Professional Online Services (HPOS) and allows you to check the patients MBS history and your eligibility for MBS billing items and check for any conditions related to these items. To check your items you will need to log in to HPOS, select ‘Items’ from the main menu, select ‘MBS Items Online Checker’, enter the patient’s Medicare details. Declare you have received the patient’s consent, select your location, select the appropriate tab for your item number, select the item number you want to check and click search. Your eligibility for billing these item numbers and any related conditions will then be accessible for you. To find out more information about the MBS items online checker, please see the following link – http://medicareaust.com/INFO/HPOS/HPOSM03INFO.pdf
ProMBS is a 1-day workshop with mixed learning modules to help you understand the MBS billing and encourages sustainable and safe billing practice. This course is also accredited with RACGP and ACRRM. You can find out more about the workshop at this link: https://www.aogp.com.au/prombs-workshop/
Understanding MBS for Rural General Practice – NSW Rural Doctors Network
This course contains various modules that address information about MBS claiming that is commonly asked by GPs in NSW. There are 11 modules and each module goes for a minimum of 1 hour. This course is accredited with both RACGP and ACRRM. You can find out more about this course at this link: https://www.thinkgp.com.au/understanding-mbs-rural-general-practice
MBS Workshops – Business for Doctors
Business for Doctors runs seminars and has video training available to help explain the different categories and how to use/read the MBS book correctly. For further information on these events, you can visit the following link: https://businessfordoctors.com/events/
Medicare Billing Assurance Toolkit
The Medicare Billing Assurance Toolkit includes a range of checklists, templates and suggestions to make it easier for Practitioners to manage risks that can cause incorrect billing under Medicare. This toolkit was developed by the Department of Health and more information can be found at this link: https://www.health.gov.au/internet/main/publishing.nsf/Content/medicare-bill-assur-toolkit
Is this system audited?
The simple answer is yes. The Department of Health detects any inappropriate practice or incorrect claiming through various systems and will conduct audits into a GPs billing to ensure no inappropriate practice has occurred.
Incorrect billings and inappropriate practice will be detected through the following methods:
- Monitoring and comparing the claiming profiles of health professionals to identify inconsistencies
- Identifying unusual patterns of item usage and item combinations
- Identifying and applying patterns learned from previous cases of non compliance
- Investigating ‘tip offs’
In addition to this, random audits will be completed to ensure these systems are not missing any occurrences of inappropriate practice or incorrect billing. When an audit is going to be conducted, the Department of Health will request for any documents related to specific services to be provided before they conduct a review of your practice.
What happens if I do it incorrectly?
If you are audited and found to be billing incorrectly, both yourself and the practice may be responsible for the repayment of compliance debts and the Medicare billings.
Whilst the GP is solely responsible for their billing, the Department of Health has recognised that Medicare billing is regularly delegated to non-practitioners and can be influenced by organisation processes and policies. For this reason, the Shared Debt Recovery Scheme was introduced and practices are now also responsible for ensuring claims that are submitted are not misleading or incorrect.
The Shared Debt Scheme means that a Practitioner can request for the practice to be considered as a potential secondary debtor. If the practitioner is found to be non-compliant the Department will provide both the practitioner and practice with a notice that they are considering a shared debt determination. This notice will include the amount of debt, the proportion of debt that will be recovered from each party and the reasons provided in relation to the debt. After receiving this notice, both parties will be provided with the opportunity to make a submission on if the debt should be shared and the percentage of debt that should be paid by each party. After receiving this information, the Department will make an official decision about the percentage of debt to be paid by both parties.
The default percentage for the shared debt is 65% for the Medical Practitioner and 35% for the Practice. If you would like another percentage to be considered, you will need to make this request and provide reasoning when you receive the notice of non-compliance from the Department.
Professional Services Review
Any cases of inappropriate practice will be investigated by the Professional Services Review (PSR) team. The role of PSR is to protect patients and the community from the risks associated with inappropriate practice and to protect the Commonwealth from having to meet the costs of inappropriate practice.
The PSR define inappropriate practice as ‘practice conducted by a practitioner that a practitioners’ peers could reasonably conclude was unacceptable to the general body of their profession.’
Information used to determine if inappropriate practice occurred include the following:
- Whether the service provided meets the requirements of the MBS or PBS item descriptor
- Whether the circumstances in which services were rendered constitute a prescribed pattern of services
- Whether there were exceptional circumstances affecting the rendering of professional attendances on each or any of the days included in a prescribed pattern of services
- Whether or not a practitioner kept adequate records for Medicare services they have rendered
There are three stages for a review, which we have outlined below:
Stage 1 – Review by the Director
The Director will look over the information provided regarding the provision of services over a period of time and determine if there is sufficient evidence that would enable a committee of peers to determine if inappropriate practice has occurred.
During this stage, if the Practitioner is willing to acknowledge their inappropriate practice, they may be able to seek an agreement with the Director.
After completing the review, the Director will either:
- Take no further action
- Negotiate an agreement under Section 92 of the Act
- Refer the practitioner to a peer review committee
Stage 2 – Review by a Committee
If the Director refers you to the peer review committee, you will proceed to Stage 2. The members of the committee are drawn from a panel appointed by the Minister and the committee is responsible for determining if the general body of their peers would find the practice appropriate or not.
If the committee believes that inappropriate practice has been engaged in during the initial review then a hearing will be held. This provides the practitioner the opportunity to present both oral and written evidence to support their case. The committee will consider all evidence provided and create a Draft Report with their findings. The Practitioner is then able to make a submission on the Draft Report which the committee will look over and decide if it changes their decision. The committee will then issue a Final Report to the practitioner and the Determining Authority.
If no inappropriate practice is found to have occurred, the matter will be closed.
Stage 3 – Determining Authority
The Determining Authority is responsible for setting an appropriate outcome based on the inappropriate practice that has occured as detailed in the committee’s Final Report. They have two main functions, as detailed below:
- Decide whether to ratify the negotiated agreements reached between the Director and a Practitioner
- Determine what sanction to apply if the Committee finds the Practitioner has engaged in inappropriate practice
The following sanctions can be applied depending on the Determining Authority’s review:
- A reprimand
- Partial disqualification from claiming a Medicare benefit for no more than three years
- Full disqualification from claiming a Medicare benefit for no more than three years
- An order for repayment of any Medicare benefits for services provided in the review period that have been found as being provided inappropriately
- A full disqualification from the PBS for no more than three years
The Determining Authority will prepare a Draft Determination of which sanctions it intends to impose and will provide the Practitioner with time to make a written submission if they do not agree with the sanctions. The Determining Authority will then make a Final Determination with the final decision on PSR and this process will have concluded.
If a Practitioner would like to fight this decision, they will need to appeal to the Federal Court or Federal Magistrates Court.
You can review previous case outcomes at this link: https://www.psr.gov.au/publications-and-resources/case-outcomes
The consequences you may receive as a result of inappropriate practice can be significant, so it is important to ensure you have an adequate understanding of any items you are billing and are confident that you could provide adequate reasoning for your billings if required. If you do not feel confident in your billing, we would suggest participating in Medicare billing training to ensure you are using the correct item numbers in your practice.
How can I provide feedback on changes that I think should be made to MBS?
The MBS Review Taskforce considers how the MBS items can be better aligned with contemporary clinical evidence and practice and improve health outcomes for patients. They also consider if any services are obsolete, outdated or potentially unsafe. The Taskforce welcomes feedback from stakeholders in order to shape their recommendations to the government. You can provide the Taskforce with feedback by emailing MBSReviews@health.gov.au
After receiving the recommendations from the Taskforce, the Government will review their suggestions and will generally conduct further consultations. Based on the Taskforce’s suggestions, numerous changes have been made by the Government to update the MBS.
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Information from this blog has been taken from the following resources:
People Medical Consulting are a team of professionals with a passion for guiding those specialising in the Medical industry to find their career pathway and settle into Australia. Working with both Australian trained and Overseas trained professionals, we have extensive experience in Recruitment of General Practitioners and Document Assistance for those requiring support with RACGP, AHPRA, 19AA and 19AB Medicare Exemptions.