OH 2020/0718
Answer
No.
Context
Question: Wanting to confirm that if a patient is on a chemotherapy regime at a hospital and the doctor goes on holiday, can we still bill for treatment to the doctor, as they created and approved the treatment pathway?
For example: A patient has chemotherapy scheduled on Thursday, their doctor goes on holiday on the Wednesday, so the covering doctor sees the patient and bills for a consult code. The patient’s usual doctor (who is on holiday) is still allowed to bill for the treatment code though, as they created the pathway. Is that correct?
Relevant legislative provisions
Other Relevant Materials
N/A
Case law
Commonwealth v Bakare (unreported). ABC reporting of the decision at this link.
El Rakhawy v The Queen [2011] WASCA 209
Canning v Northcott (Unreported), WASC, Library No 7194, 14 July 1988
Departmental interpretation
N/A
Detailed Reasoning
Knowingly billing for services not provided is fraud, and the above cases all involve medical practitioners billing for services they did not personally provide. In some instances, the doctors billed while they were overseas and all were found criminally liable. One practitioner, Dr Bakare, is currently in jail.
Needless to say this is very serious.
The most fundamental principal of Medicare billing is that a provider has to provide a service, to bill a service. You cannot claim for doing nothing. Even when invoking the supervision arrangements, there is still a positive onus on the supervising provider to be actively involved in the service being supervised, evidence of which must be recorded in the patient’s clinical records.
A medical practitioner cannot bill to Medicare while on holidays. While on holidays, usual practice is that the treating medical practitioner will arrange a locum, and the locum will take over and bill in their name and provider number.
For clarity, a treating medical practitioner cannot supervise a locum. The locum arrangements are designed so that locums take over full responsibility for the treating doctors patients during the locum period, and consequently, are entitled to claim all relevant Medicare benefits.
I hope this is clear. The correct way to bill the scenario described in this question is that the locum or ‘covering doctor’ bills everything under her/his name and provider number and the holidaying doctor must not bill anything.
Please also see answer GA 2020/065 about billing while overseas.
Examples and other relevant information
N/A
Who this applies to
Everyone
When this applies
Always