Bulk bill claims in Medicare 011-43030000

The Department of Health and Aged Care have provided policy advice on assignment of benefit for face to face bulk-billed services during the Covid-19 pandemic.

Where a patient is seen face to face and the health professional chooses to bulk bill, reasonable steps must be taken to get a signature agreement. For example:

• Written signature
• Medicare easy claim, patient selects either the OK or yes button on the EFTPOS terminal
• Email agreement, or
• Signature of a responsible third party

However, if the patient refuses to sign the form, that is, does not want to touch the pen or paper, the practitioner can get the agreement verbally. To do this the health professional must:

• Identify on the form that the patient is unable to sign the assignment of benefit and include the reason. For example, COVID-19, risk of exposure to COVID-19, verbal agreement given
• Note the verbal agreement of assignment of benefit in the patient’s clinical notes

Note: this policy is a temporary measure.

Manual bulk bill claims

To support this temporary policy, bulk bill manual claims received with a date of lodgement from 13 March 2020 can be accepted, where the following has been provided:

• A completed header, signed by the health professional and witness
• An assignment of benefit form with:
• patient’s signature, or
• the reason why the patient is unable to sign the assignment of benefit form, for example, COVID-19, risk of exposure to COVID-19

Note: this policy only applies if the patient refuses to sign because they do not want to touch the pen and/or paper. The above details do not replace existing policy for all other unable to sign/blank signature’ scenarios.

For details about COVID-19 services see Temporary Medicare Benefits Schedule (MBS) items in response to Coronavirus (COVID-19).

If health professionals cannot get patient agreement in writing or by email for telehealth services, they can get verbal agreement from their patient during the telehealth consultation.

Health professionals must complete the form approved for the purposes of s 20A of the Health Insurance Act 1973 electronically:

• Bulk bill voucher - electronically transmitted claims form (DB4E)
• Assignment of benefit Medicare bulk bill Webclaim form (DB020)

The Resources page contains links to the forms.

Health professionals must:

• explain to the patient how they will fill in the patient signature field in the approved form, and
• confirm that the patient agrees

If the patient agrees, health professionals must:

• type patient verbally agreed in the patient signature field, and
• send the completed form electronically to the patient

If the patient does not agree to assign their benefits, the health professional can send them a private bill for the service.

Health professionals should keep a copy of all correspondence, claims, and forms for at least 2 years. This is for auditing purposes if they are subject to a compliance review.

Getting verbal agreement is a temporary measure.

Note: patients can also assign their right to a Medicare benefit by email.

The Resources page contains a link to the Email agreement on the Services Australia website for more details.

Bulk billing:

• also known as direct billing, is when a health professional bills Medicare directly for any medical or allied health service that a patient receives
• is available to all persons in Australia who are eligible for a Medicare benefit under the Medicare program

Where a health professional and a patient enter in to a bulk bill arrangement, the:

• servicing health professional undertakes to accept the relevant Medicare benefit as full payment for the service. Additional charges for that service cannot be raised, and
• patient assigns their right to the Medicare benefit to the servicing health professional, allowing the benefit to be paid directly to the health professional

Health professionals must lodge claims for assigned benefits in accordance with the approved forms and within a period of 2 years from the date of service.

See also: Bulk bill latter day adjustment (LDA) claims in Medicare.

There is no minimum age restriction for a patient to assign their right to a Medicare benefit to the servicing health professional. However, the patient must have the capacity to understand what they are signing. Health professionals must use their discretion to determine a patient’s capacity.

Bulk billing cannot be used as a form of debt collection for unpaid accounts.

Note: section 20A of the Health Insurance Act 1973 allows a patient to assign their right to a Medicare benefit to the health professional who has rendered the service.

The Resources page contains a link to the Medicare Benefit Schedule (MBS) Online Explanatory Note GN.7.17, which has more details about bulk billing.

A patient can assign their right to a Medicare benefit to the servicing health professional by signing a completed and approved assignment of benefit form for manual and online claiming. The patient or other responsible person must not sign a blank or incomplete assignment of benefit form.

Under section 20B (3) of the Health Insurance Act 1973, a copy of the completed form must be given to the patient or other responsible person after the patient has signed the form.

The Resources page contains a link to Medicare Online for health professionals page on the Services Australia website. This page includes details about assignment of benefit documents.

Note: for Medicare Easyclaim, patients assign their right to a Medicare benefit by pressing the OK or YES button on the EFTPOS terminal in the practice.

Under section 20A (2) of the Health Insurance Act 1973 a patient can make an offer to assign their Medicare benefit to an approved health professional.

Where the requesting health professional (for example, general practitioner (GP)) collects the pathology sample instead of the Approved Pathology Practitioner (APP), the patient may complete an assignment of benefit voucher for the APP’s service at the time of the visit.

The Resources page contains a link to Medicare Benefits Schedule - PN.7.1 assignment of Medicare benefits - patient assignment.

If a patient is unable to sign an assignment of benefit form a signature of one of the below is acceptable:

• Patient’s parent
• Guardian
• Other responsible person

In the absence of a parent, guardian or responsible person, the ‘patient signature’ section should be left blank.

Where the signature space is either left blank or another person signs on the patient’s behalf, the assignment of benefit form must include:

• the notation 'Patient unable to sign', and
• in the 'Practitioner’s Use' section, the reason why the patient was unable to sign, for example, unconscious, injured hand

For Medicare Easyclaim, consent from the patient, the patient’s parent, guardian or other responsible person is acceptable by pressing the OK or yes button on the EFTPOS terminal.

Responsible person

'Responsible person' refers to an adult person accompanying the patient or in whose care the patient has been placed. A responsible person can include someone who:

• is the parent or guardian
• holds power of attorney
• holds a guardianship order
• is the next of kin

This does not include the:

• health professional who rendered the service
• health professional’s staff
• hospital proprietor or staff, or
• residential aged care facility proprietor or staff

Patient unable to sign - sensitive issue

If the health professional determines that the reason the patient is unable to sign is of a highly sensitive nature, they can notate 'due to medical condition' or ‘due to sensitive condition’ in the 'Practitioner’s Use' section.

This would only be the case if revealing the reason would:

• constitute an unacceptable breach of patient confidentiality, or
• unduly embarrass or distress the recipient of the patient’s copy of the assignment of benefit form

Note: this should not be routine practice, and ‘extenuating circumstances’ is not acceptable notation for the lack of patient signature.

If the claim is a resubmission of a previously submitted claim, refer to the section Bulk bill resubmissions for more details.

Patient unable to sign- deceased

The health professional and patient must have entered into a bulk bill agreement at the time of service including having the patient sign the assignment of benefit form.

Where a signature is not obtained from a patient, a signature from a responsible person is acceptable. A responsible person can be:

• the executor of the will
• an appointed administrator

Note: the notation ‘patient deceased’ is not a sufficient reason for a health professional not obtaining a signature on the assignment of benefit form. A signature must be provided on the assignment of benefit form, from either the patient or the responsible person.

Where a health professional and a patient enter into an agreement under section 20A of the Health Insurance Act 1973 the agency will accept a patient’s signature electronically provided the below conditions are met:

• The electronic device used to capture the signature is able to replicate the existing form approved for the purposes of subsection 20A(1) of the Health Insurance Act 1973
• The signature on the electronic device is reliable and identifies the patient and indicates that patient’s intention to assign the Medicare benefit
• The use of the device is in accordance with any information technology requirements specified by Medicare
• For the purposes of section 127 of the Health Insurance Act 1973 the particulars relating to the professional service be set out on the approved assignment of benefit form before the patient signs the agreement, and
• A copy of the assignment is given to the patient as soon as practicable after the patient signs the agreement

The References page contains a link to the Electronic Transmission Act 1999.

A patient’s refusal to sign the assignment of benefit form:

• is different to a patient being unable to sign the form. Where a patient refuses to sign the form, this is a matter between the patient and the health professional
• means that the patient and the health professional cannot enter into an agreement for bulk billing

If a health professional bulk bills for a service, the health professional undertakes to accept the relevant Medicare benefit as full payment for the service. Additional charges for that service cannot be raised.

This includes but is not limited to:

• any consumables that would be reasonably necessary to perform the service, including bandages and dressings
• record keeping fees
• a booking fee to be paid before each service
• an annual administration or registration fee

Exception

An additional charge can only be raised against a bulk billed patient if the patient is given a vaccine or vaccines from the health professional’s own supply held on the premises.

This exception only applies to general practitioners and other non-specialist health professionals in association with attendance items 3 to 96 and 5000 to 5267 (inclusive). It only relates to vaccines that are not available to the patient:

• free of charge through Australian Government or state government funding arrangements
• through the Pharmaceutical Benefits Scheme (PBS)

The additional charge must only be to cover the supply of the vaccine.

Where a health professional chooses not to bulk bill a patient, they may privately raise an additional charge against a patient, such as for a consumable.

The Resources page contains a link to the Medicare Benefit Schedule (MBS) Online Explanatory Note GN.7.17, which has more details about bulk billing.

Health professionals can submit their Medicare bulk bill claims:

• electronically through Medicare Bulk Bill Webclaim, or
• by ordering manual bulk bill forms by completing a Medicare stationery order form

Medicare Bulk Bill Webclaim can be accessed using HPOS. If the health professional does not have HPOS access, they need to apply for Provider Digital Access (PRODA) to be able to access HPOS.

Note: manual bulk bill forms were removed from the agency website on 15 May 2017.

A valid claim must include the appropriate bulk bill claim header for the assignment of benefit form(s) used. The header can only be signed by the servicing health professional.

Services that were performed as in-patient and out-patient services cannot be ‘batched’ together and submitted under the one claim. These claims need to be submitted separately and the appropriate header completed.

All fields on the manual bulk bill claim header are expected to be completed by the health professional. However, there a few exceptions to this, which are listed below:

• witness name for sole health professionals
• payee provider section (only completed where the payee and servicing health professional are not the same)
• missing or incorrect information that may be confirmed over the phone

The Process page contains more details.

A 'Signature of Witness' is required on all manual bulk bill claim headers. An eligible witness is a person who works at the health professionals practice but is not the person or health professional who:

• rendered the service, and
• signed the declaration

Note: sole health professionals who cannot get a witness signature on the bulk bill header must notate 'sole practitioner' in the witness signature field.

Where a patient is unable to provide their Medicare card number to the health professional, the health professional may get it by:

• using the Patient Verification facility through HPOS
  Note: this facility is only available to health professionals with a Public Key Infrastructure (PKI) site certificate or with registration for Provider Digital Access (PRODA)
• calling the Medicare provider enquiries line for exempted groups only

For more details, see 'Medicare card enquiries' in Release of claims information in Medicare.

Medicare card close to expiry date or has expired

If the Medicare card used in a bulk bill claim is within 75 days either before or after the expiry date, the bulk bill statement tells the health professional that the card is about to, or has, expired.

See also: Indicators, codes, modifiers and control lines for claims processing in Medicare.

Alterations on bulk bill claims not previously processed

When a bulk bill claim is having an initial assessment and details on the assignment of benefit form have been altered, the health professional does not need to:

• have the patient initial or endorse the alterations to indicate that they are aware of and agree to the alterations
• complete a new assignment of benefit form with the correct details and have the patient sign the new form before submitting to the agency for processing

See also: Bulk bill late lodgement claims in Medicare.

Inappropriate alterations to assignment of benefit forms

It is an offence under section 128A, 128B and 129 of the Health Insurance Act 1973 for a servicing health professional to make a false or misleading statement in relation to a Medicare claim. The servicing health professional must not under any circumstances amend any details, for example, an item number, simply because the agency rejected the original claim.

The Resources page contains links to assignment of benefit and Application for bulk bill claim adjustment forms.

Contact Medicare Public Local Peer Support (LPS) for help with processing a patient claim when the:

• claim is received via the PaNDA work tool
• claimant has an RHCA entitlement, and
• claimant has already left the country

Where the servicing health professional asks about the payment of a manually submitted bulk bill claim that has not been received, Service Officers must ask them if they retained a copy of the claim.

Note: the copy of the claim retained by the health professional must include a signature from the patient on the assignment of benefit form.

Health professional has retained a copy of the claim

If the health professional has retained a copy of the claim, they must do the following:

• photocopy all of the assignment of benefit forms within the claim
• resend the claim to the agency
• attach a brief covering letter explaining the reason for the photocopied claim being submitted

Note: if the photocopied assignment of benefit forms are missing any details from the original forms, it is acceptable for the servicing health professional to add these details to the photocopied form(s). For example, if the details were stamped on the original and this did not transfer to the practitioner copy..

The agency will accept the photocopied assignment of benefit forms if:

• the information on the form is clear, and
• there is no evidence suggesting alterations have been made .

Health professional has not retained a copy of the claim

If the health professional has not retained a copy of the claim, they must:

• complete the assignment of benefit form(s) with the original service details
• get the patient’s signature
• complete a bulk bill claim header
• send the claim to the agency for processing

Note: while health professionals are no longer required to retain a copy of the bulk bill forms, the agency suggests they retain a copy until the account has been reconciled.

The Resources page contains links to various bulk bill forms on the Services Australia website.

All heath professional bulk bill payments are made via EFT. A health professional must have their bank details stored with the agency in the Provider Directory System (PDS) in order to receive bulk bill payments.

Health professionals that have not registered their EFT details and lodge bulk bill claims will have their payments HELD. Once the health professional registers their nominated bank account, any HELD Medicare benefits will be automatically released by the system.

A list of EFT payments can be viewed by keying control line BRNA. This transaction will allow a view of specific Medicare deposits for a provider number.

The data available via the BRNA transaction is updated daily, See Medicare benefit not received (EFT dispute).

A bulk bill EFT dispute is when a health professional states they have not received a Medicare benefit into their nominated bank account for a claim that was processed and not rejected.

Service Officers are to determine the reason the health professional has not received their Medicare benefit as claimed. For example, HELD payment, claim rejected or not processed.

Health professional error

If the health professional provided incorrect bank details to the agency, Service Officers must complete an EFT dispute form and forward to MPS Assessing.

If a claim is processed against the wrong health professional and it can be identified who received the payment, Service Officers must:

• complete a Customer enquiry form, and
• forward the form to MPS Assessing, noting overpayment details

If an EFT retrieval is unsuccessful where the health professional has provided incorrect information, the agency is not obligated to repay the funds.

Agency error

If a Medicare benefit was paid into an incorrect bank account due to agency error, the agency must repay the health professional at the first point of contact.

If it is:

• known where the incorrect payment was made, raise a debt through MPS Assessing
• not known where the incorrect payment went, complete a Medicare EFT Dispute Form and send via email to MPS Assessing

Note: repayments can only be actioned by Service Officers with the appropriate skill tag.

Bulk bill resubmissions are Medicare bulk bill claims that have been resubmitted by a health professional with additional or amended details. Resubmissions generally occur after a claim header or assignment of benefit form is returned or rejected due to missing or incorrect information, such as:

• Incomplete or incorrect Medicare card number or patient details
• Bulk bill header or assignment of benefit form is incomplete. For example, health professional and/or patient has not signed the assignment of benefit form
• Claim information such as the item number or referral details

Health professionals resubmitting a bulk bill claim header or assignment of benefit form that has been previously rejected by Medicare, must lodge the resubmitted claim with all the required paperwork.

Each type of resubmission has different requirements in order for the claim to be processed. If there are missing documents or paperwork, the claim must be returned with the appropriate letter.

A health professional can resubmit a claim electronically for the same service if:

• an electronic bulk bill claim is rejected, and
• the patient has initially signed the assignment of benefit form

If the claim cannot be resubmitted electronically, and to determine the required paper work, Service Officers must identify if the claim is for:

• an initial assessment, or
• a resubmission of a previously rejected service

Resubmission of a previously rejected claim for the same service

Where a practice cannot resubmit the claim electronically, they must provide Medicare with the following documents:

• a completed header, signed by the servicing health professional and witness, and
• an assignment of benefit form accompanied with either:
• a patient signature
• letter indicating the claim was originally submitted electronically, or
• a notation that the ‘patient has signed the Medicare copy’, where there is evidence either on the patients mainframe history or PaNDA that the claim was payable at the time of the original submission

Note: this only applies where there has not been a change to the original details of the claim (e.g. item number, DOS etc.).

Resubmission of a previously rejected claim for a different service

The patient must sign a new assignment of benefit form that reflects the correct service, if:

• an online bulk bill claim is rejected, and
• the practice must resubmit the claim for a different service to the original

If agreement is obtained from the patient for the correct service, the practice can resubmit the claim for the service electronically.

Where the practice cannot submit the claim electronically, they must provide Medicare with the following documents:

• a completed header, signed by the servicing health professional and witness
• a completed assignment of benefit form signed by the patient

Resubmission of a previously rejected Easyclaim bulk bill claim

For a resubmission of an Easyclaim, the following documents are required:

• a completed header, signed by the servicing health professional and witness
• copies of the Easyclaim printout / slip, and
• a signed letter on a practice letterhead stating that the original claim was submitted through the Easyclaim channel

Service Officers must determine if the claim received is for the same service as the original or if the resubmission is for a different service if:

• a manual claim has been rejected, and
• the practitioner is required to resubmit the claim

Resubmission of a previously rejected claim for the same service:

• a completed header, signed by the servicing health professional and witness
• assignment of benefit form accompanied with either:
• a patient signature
• a notation that the ‘patient has signed the Medicare copy’, where there is evidence either on the patients mainframe history or PaNDA that the claim was payable at the time of the original submission

Note: copies of the original forms are acceptable where the claim is resubmitted for the same service.

Resubmission of a previously rejected claim for a different service:

• a completed header, signed by the servicing health professional and witness
• a completed assignment of benefit form signed by the patient

Health professionals are no longer required to keep a copy of the assignment of benefit forms where the claims are lodged electronically. The agency recommends that the copies are retained until the account has been reconciled.

Health professionals that submit their claims manually are required to retain the copy of the assignment of benefit form for up to 2 years.

For electronic claims, health professionals can demonstrate that a service was provided through records such as:

• notes in practice software
• appointment records, or
• the practitioner copy of the assignment of benefit form

Where a health professional cannot demonstrate that a service was provided to a patient, they must retain the practitioner copy for 2 years from the date of service.

The Resources page contains a table outlining disposal action of records as stated in Entry 20173 of the National Archives of Australia - Records Authority - Medicare.

The agency retains bulk bill claim forms that have been submitted for a period of 2 years, where a benefit is paid to the health professional.

All assignment of benefit forms, accounts or account receipts for processed claims must be retained by the agency for audit purposes. These documents provide the only reliable audit evidence in support of the payment of Medicare benefits.

See also:

Account and receipt documents for Medicare claims processing

Archiving and document retrieval for Medicare

When a bulk bill claim is received for initial assessment (that is, a bulk bill claim not previously processed by the agency) and details on the assignment of benefit form have been altered, the health professional is required to have either:

• the patients initials endorsing the alternations to indicate they are aware of and agree to the alterations, or
• complete a new assignment of benefit form with the correct details and have the patient sign the new form before submitting to Medicare for processing

Bulk bill statements are mailed to the payee provider at their current preferred mailing address, as per their stem details in the Provider Directory System (PDS). Manually requested statement are printed daily and should be received within 10 working days.

Health professionals can subscribe to the HPOS Mail Centre to receive copies of statements or reports, including Medicare bulk bill (manual claiming) reports. Health professionals subscribed to the above statements on HPOS, or who lodged the claim via HPOS, do not receive paper statements from the agency. They must access their statements via HPOS.

See Related links for a link to ‘Requests for provider statements for eBusiness/eServices’ for more details.