service being charged to the patient
outside of the Medicare scheme. If the
specialist service is not claimable then
neither is the patient-end service, and
an MBS item number should not be
claimed, but more about that shortly.
with the answer lying buried deep
in the health-law labyrinth of acts
and agreements. Consider the
following examples.
care facility attends an outpatient
appointment at a public hospital by
video consultation from their local
general practice. The specialist they
see does not bill the patient because
they choose not to exercise their right
of private practice in this particular
situation. Can the GP or other eligible
healthcare provider bill a telehealth
item number for assisting with
the consultation?
is not claimed, or visa versa?
to the GP for an arranged public
hospital outpatient appointment,
does the residential aged-care
facility exemption still apply?
the patient, not the provider. The legal
validity of our national health scheme
rests on the constitutional guarantee
provided in s51(xxiiiA), ensuring
Medicare rebates are always payable
service has been provided, a patient
can choose to assign their right to the
Medicare rebate to the provider, which
we all know as bulk billing.
exercising a right of private practice
but whether a claim can lawfully be
raised against the patient. In general
terms, if the patient is a public patient
in a public hospital, Medicare benefits
cannot be claimed. If the patient is
private, Medicare benefits can be
claimed, and telehealth services can
only be claimed when the patient is
located in an eligible telehealth area
and the two providers are at least 15
kilometres apart. Easy!
claimed and an item being claimable.
The key machinery provisions of the
Health Insurance Act 1973 are sections
10, 20 and 20A. Section 10 creates
an entitlement to a Medicare benefit,
section 20 sets out who obtains
that entitlement and section 20A
provides for the assignment of the
entitlement. Nowhere in the Act is
there a further provision giving rise to
a legal compulsion to claim or collect
the entitlement. In fact, it's quite the
opposite. Providers have two years in
which to submit claims, after which a
late lodgement application is required
to show cause as to why benefits should
be paid after so long. Sound policy
when you consider that the current
cost of Medicare claims (not including
PBS claims and the grants to the states
to fund public hospitals) is in the
vicinity of $22 billion per annum.
claim can lawfully be raised against
on whether the specialist chooses
to claim, but whether the patient is
physically in an approved telehealth
location where a Medicare service can
be claimed.
services, the specialist service takes
precedence over the patient-end service
and must be claimable before the
patient-end service will be claimable.
But the two are not interdependent,
in that there is no necessity for both
services to be claimed.
patient is in a telehealth eligible area.
location at the time the consultation
takes place. This is pretty simple
if the patient had stayed in the
residential aged-care facility. Under
the exemption the service would have
met the telehealth requirements, and
the patient-end service would have
been claimable even if the specialist
had chosen not to lodge a claim.
remain a telehealth-eligible service
if the GP's surgery was located in an
eligible telehealth area. If not, this
service would no longer meet the
telehealth criteria.
telehealth-eligible service. But if the
GP's surgery is not in a telehealth-
eligible area (such as metropolitan
Melbourne), it is not claimable as a
telehealth service.
attendance if all other requirements