OH 2020/0719
Answer
Yes.
Context
Billing to Medicare for non-admitted patients in public hospital emergency departments is strictly prohibited, even if patients have private health insurance and are happy to use it. This is provided for in various provisions of both the Health Insurance Act 1973 and its intersection with the National Health Reform Agreement.
However, in this scenario, Dr A was a haematologist who worked at a private hospital with a private emergency department (ED). Dr A wanted to know whether non-admitted patients in the ED could be billed to Medicare and whether the patient would be entitled to a Medicare rebate.
Further, Dr A wanted to know at what point a patient is considered an inpatient after a decision to admit has been made, so that the patient’s private health insurer (PHI) could be billed. Was it:
- When the patient is physically out of the ED and on the ward, or
- When a decision has been made to admit the patient but the patient is still in the ED, or
- When the patient’s admission status has been changed in the hospital administration system indicating the patient is an inpatient.
Relevant legislative provisions
Health Insurance Regulations 2018
Other Relevant Materials
Approved Private Emergency Department, Program Guidelines, available at this link on the Department of Health Website (accessed 19 July 2020).
Case law
N/A
Departmental interpretation
Below quotes are taken from the official private ED program guidelines at this link.
“An approved private hospital emergency department is a hospital emergency department that has been approved by the Department of Health for the purposes of the Approved Private Emergency Department Program.”
“The Approved Private Emergency Department Program is an approved program under section 3GA of the Act. The Department of Health is the administering body. Medical practitioners working in the Approved Private Emergency Department Program for approved service providers will be listed on the Register of Approved Placements under section 3GA of the Act. A Medicare benefit would then be payable in respect of specific emergency medicine services performed by such doctors (provided that any other applicable eligibilty requirements for benefits are also satisfied).”
Detailed Reasoning
IMPORTANT: First please note that Dr A was a specialist and therefore met the threshold requirement to claim Medicare benefits. This does not apply to all medical practitioners. There are restrictions placed on overseas trained practitioners and those who have not completed or who are not enrolled in relevant training programs. The above link to the program guidelines explains the restrictions and is recommended reading.
Section 19AA of the Health Insurance Act 1973 cross references section 3GA, which links to the Regulations, the net effect being that only suitably qualified or supervised medical practitioners are permitted to claim Medicare benefits in private hospital EDs. Specialists such as Dr A meet the requirements.
Dr A can therefore claim using usual Medicare item numbers for services provided while patients are in the private ED, including for services provided before any decision to admit has been made. Item numbers that would likely be relevant would be attendances, including both initial and subsequent attendances depending on whether the patient is new to Dr A or is already under Dr A’s care.
Dr A has the same claiming options available as in any private outpatient setting and can bulk bill or charge a gap. If Dr A chooses to charge a gap, the patient would be required to pay the full fee and claim back the Medicare rebate which will be 85% of the Medicare schedule fee.
As to the second part of the question, the correct answer is option 3, when formal administrative processes have been completed and the patient is deemed admitted. This is not easy to determine in practice, and I often suggest applying what I call – the wrist/ankle band test!
When a patient is formally admitted to a hospital, usually (though not always) the last thing that happens is wrist and ankle bands are attached to the patient. This is a strong signal the patient has been admitted. However, someone can be slow to apply the bands, and equally, once discharged, patients can forget to cut them off. I have seen this cause claiming errors so please be careful. If possible, ask the admissions clerk (if there is one) whether and when the patient was admitted and commence claiming to the patient’s PHI from that point forward.
Please note that the PHI is not able to cover any services provided prior to admission and it may be helpful to explain this to your patients. The below quote from a colleague who had worked for over a decade for PHIs explains this:
“When I worked in health insurance the private hospitals were starting to open up their own emergency departments. The problem was that the ambulance would take the patient to the nearest hospital and if the patient had private cover they would tell the ambulance driver who would take them to the nearest private emergency department. Once home and better they were receiving bills for everything that was done in the emergency department. They would send these claims to their PHI and, because they were not admitted into the hospital while in emergency, we could not cover them. This prompted a lot of very unhappy members because they believe that by having private health insurance they should be able to use it in the emergency department of a private hospital.”
Examples and other relevant information
Because Dr A is a specialist haematologist, the Medicare rebate for outpatient services is 85% of the Medicare schedule fee. However, if the servicing provider was a GP, the usual rebate would be 100% of the Medicare schedule fee, depending on item numbers.
Who this applies to
Specialists working in private emergency departments.
When this applies
Since 1988 when private emergency departments were first established, though formal program guidelines were only published in June 2019.