GA 2021/0230
Answer
No.
Context
The question posed was: “Cardiologist, Dr Z, performs a procedure (permanent pacemaker implant) at hospital A (provider number 1), but would like to see the patient for ongoing care/follow up at practice B (provider number 2). Can Dr Z self-refer for the follow up visit?”
Relevant Legislative Provisions
Health Insurance Regulations 2018
Other Relevant Materials
Please read this answer in conjunction with GA 2021/0126
Case law
N/A
Departmental Interpretation
Relevant content in the MBS (accessed 20 January 2021)
(iii) Hospital referrals.
Private Patients – Where a referral is generated during an episode of hospital treatment for a service provided or arranged by that hospital, benefits will be payable at the referred rate if the account, receipt or assignment form is endorsed ‘Referral within (name of hospital)’ and the patient’s hospital records show evidence of the referral (including the referring practitioner’s signature). However, in other instances where a medical practitioner within a hospital is involved in referring a patient (e.g. to a specialist or a consultant physician in private rooms) the normal referral arrangements apply, including the requirement for a referral letter or note and its retention by the specialist or the consultant physician billing for the service.
Detailed Reasoning
Referral law is one of the most confusing areas of Medicare billing, yet it is fundamental to every encounter between a patient and a medical specialist.
The answer to this question will be brief because most of it has been answered in GA 2021/0126. Please read that answer before reading this one.
PLEASE NOTE: It is unclear whether this patient was a public patient in a public hospital, or a private patient in a public hospital, or a private patient in a private hospital. If the patient was a public patient in a public hospital, the patient should be discharged to the care of his/her GP, or can be directed to return to the public hospital outpatient department. In these circumstances, the patient should not be coerced or directed to a private cardiologist for routine follow up care. If a patient returns to the outpatient department, they must be seen and treated with or without a referral (but they cannot be billed to Medicare without a named referral). If the patient's GP determines that follow up care by a cardiologist is required, and the patient agrees, then a new GP referral can be used by the patient to see the cardiologist in his/her private rooms.
Some services in the MBS are unreferred, and some can be ‘self deemed’ but this question describes follow up care by a cardiologist, and those services involve attendances such as items 110, 116, 119, 132 and 132, all of which are referred services.
Division 4 of the Regulations sets out the ‘manner of patient referrals’ which describes how a patient can be referred to a specialist or consultant physician and who can make a referral. Self referring is not permitted and if you try it, your claims will be rejected, or your patient will be denied their rebate.
Assuming this patient was either private in public, or private in private, what is required is that the person who referred the patient to you for the PPM writes a referral for ongoing care beyond discharge, that you can store in your clinic records. You cannot rely on a referral written in the patient’s hospital records – explained in GA 2021/0126
Examples and other relevant information
The provider number part of this question is easily answered. When you are treating a referred patient you are not bound by one provider number or one location. You can treat the patient wherever appropriate throughout the period of the referral, and that will often necessitate switching between various locations and provider numbers.
Sometimes Medicare’s system does not handle this well. For example, you may bill an item 132 using provider number A, and then item 133 using provider number B, which Medicare rejects stating you have not billed a previous item 132 for the patient. The only way to resolve this is jump on the phone to Medicare unfortunately.
Who this applies to
All specialists.
When this applies
Always