Medicare benefits for professional services 011-43010010

A professional service is defined as a clinically relevant service rendered by a medical or dental practitioner, an optometrist or an eligible allied health professional.

A clinically relevant service is defined as a service that is generally accepted in the medical, dental, optometric or allied health profession, as being necessary for the appropriate treatment of the patient to whom it is rendered. Medicare benefits are paid under the Health Insurance Act 1973 (the Act) for professional services in accordance with fees set out in the Medicare Benefits Schedule (MBS).

The MBS is a publication that is maintained and updated by the Department of Health and Aged Care. Each professional services contained in the MBS has been allocated a unique item number. Located with the item number and description for each service is the Schedule fee and Medicare benefit, together with a reference to an explanatory note relating to the item (if applicable).

Services listed in the MBS must be rendered according to the provisions of the relevant Commonwealth, state and territory laws. The day-to-day administration and payment of benefits under the Medicare arrangements is the responsibility of Services Australia.

Fees for professional services

The Act allows the Australian Government to set schedule fees. However, health care professionals are free to set their own fees for the professional services they provide.

The References page contains a link to the Health Insurance Act 1973.

The gap is the difference between the Medicare benefit and the schedule fee and is payable by the patient.

People who have hospital insurance with a registered private health fund, and incur medical expenses for in-hospital services, can claim benefits from the fund for any gap amounts, provided Medicare benefits are payable for the service.

People claiming Medicare benefits for in-hospital services are provided with a statement that can be used to support a claim on their fund for any gap benefits.

Health professionals are free to set their own fees for professional services. These fees are a matter between the health professional and the patient; however, the fee must not include any component for other goods or services that are not part of the specified service (the Medicare Benefits Schedule (MBS) item).

A Medicare benefit must not exceed the medical expenses incurred for that service. Where the health professional charges less than the benefit payable, the benefit paid is reduced to the amount charged.

See References for a link to Health Insurance Act 1973, Section 14.

Although a Medicare benefit paid is a percentage of the schedule fee for a service, the full amount that the health professional charges is required and recorded as it provides:

• Evidence that an expense has been incurred
• Evidence of the out-of-pocket (OOP) amount. The system uses this amount to calculate the Medicare Safety Net benefit for that claim
• A check on the item claimed. For example, if item 'X' has a benefit of $30 and $200 is recorded as the charge, the Service Officer is prompted to check that the item number keyed matches the item number shown on the account

Where an account displays a charge that has not been rounded, follow the principle 'key as you see' and key the charges exactly as shown on the account.

Note:

• Keying charges that are not rounded does not result in a benefit that is not rounded, providing the charge exceeds the Medicare benefit payable
• When explaining the benefit paid, the Service Officers must not:
• Make reference to the level of the health professional’s charge
• Suggest the health professional has overcharged

The obligation to pay medical fees arises out of a contract between the health professional and the patient or the person responsible for the patient's medical expenses.

The Health Insurance Act 1973 recognises the contract between the health professional and the patient; therefore, a Medicare benefit is payable to the person who incurred the medical expenses for the service.

The References page contains a link to the Health Insurance Act 1973.

In general, the Medicare benefit is 85% of the fee listed in the Medicare Benefits Schedule (MBS) for the service (known as the Schedule fee).

For attendances provided by general practitioners (GP) (or on behalf of a GP) to out of hospital patients, the Medicare benefit is 100% of the listed Schedule fee.

For professional services provided to private hospital patients (admitted to either a private or public hospital) the Medicare benefit is 75% of the listed Schedule fee.

Public patients admitted to public hospitals, receive free medical and hospital treatment funded under state/territory arrangements, therefore are not entitled to Medicare benefits.

Patients in an accident and emergency department are not considered inpatient until they have been formally admitted into the hospital.

Not all services attract a Medicare benefit. The Medicare statement of benefit/receipt provides a declaration for claimants to sign. By signing the declaration the claimant is agreeing that the service/s they are claiming are not excluded from Medicare benefits under the Health Insurance Act 1973 (the Act) or the Dental Benefits Act 2008. Where a claimant requires clarification on what services are excluded, this policy assists the Service Officer in providing the claimant with further information. See Services not attracting Medicare benefits.

The References page contains links to the Health Insurance Act 1973 and the Dental Benefits Act 2008.

The Medicare Benefits Schedule (MBS) Explanatory Note titled, 'Services which do not attract Medicare benefits', states that following services do not attract Medicare benefits:

• Telephone consultations
• Issue of repeat prescriptions when the patient does not attend the surgery in person
• Group attendances (unless otherwise specified in the item, such as items 170, 171, 172, 342, 344 and 346)
• Non-therapeutic cosmetic surgery
• Euthanasia and any service directly related to the procedure, however, services rendered for counselling assessment about euthanasia will attract benefits
• Extracorporeal magnetic innervation (EMI)

The Medicare Benefits Schedule (MBS) Explanatory Note titled, 'Services which do not attract Medicare benefits', states Medicare benefits are not payable where the medical expenses for the service are:

• Paid/payable to a public hospital
• For a compensable injury or illness for which the patient’s insurer or compensation agency has accepted liability. Note: if the medical expenses relate to a compensable injury or illness for which the insurer or compensation agency is disputing liability, then Medicare benefits are payable until the liability is accepted
• For a medical examination for the purposes of:
• life insurance
• superannuation
• a provident account scheme
• admission to membership of a friendly society
• Incurred in mass immunisation, if the vaccine is specifically funded by:
• other commonwealth or state government programs
• an international or private organisation

Unless the Minister otherwise directs Medicare benefits are not payable where:

• the service is rendered by or on behalf of, or under an arrangement with:
• the Australian Government
• a state or territory
• a local government body
• an authority established under Commonwealth, state or territory law
• the medical expenses are incurred by the employer of the person to whom the service is rendered
• the person to whom the service is rendered is employed in an industrial undertaking and that service is rendered for the purposes related to the operation of the undertaking
• the service is a health screening service
• the service is a pre-employment screening service

Sporting bodies

Medicare benefits are payable for a professional service provided to a patient where that patient is employed to play sport.

Sporting bodies are classified as an employer. Professional sports players who receive an income from a sporting body are considered employees of that sporting body.

On 30 October 2014, the Minister for Health signed a direction stating that Medicare benefits are payable for persons employed to play sport. This direction applied to claims received from 25 May 2014 until 30 October 2017.

A new direction was signed by the Minister for Health on 6 March 2017, revoking the original direction signed on 30 October 2014. This new direction stated that Medicare benefits shall be payable indefinitely to a person where that person is employed to play sport.

See also: Professional services related to Medicare patient claims.

The References page for links to the Health Insurance Act 1973, Section 19 (2) and the Medicare Benefits Schedule (MBS).

Any of the services specified below are considered a non-Medicare service when associated with any item between item 3 and item 10943. These services include:

• endoluminal gastroplication, for the treatment of gastro-oesophageal reflux disease
• gamma knife surgery
• intradiscal electro thermal arthroplasty
• intravascular ultrasound, except if used in conjunction with intravascular brachytherapy
• intro-articular viscosupplementation, for the treatment of osteoarthritis of the knee
• low intensity ultrasound treatment, for the acceleration of bone fracture healing, using a bone growth stimulator
• lung volume reduction surgery, for advanced emphysema
• photodynamic therapy, for skin and mucosal cancer
• placement of artificial bowel sphincters, in the management of faecal incontinence
• selective internal radiation therapy for any condition other than hepatic metastases that are secondary to colorectal cancer
• specific mass measurement of bone alkaline phosphatise
• transmyocardial laser revascularisation
• vertebral axial decompression therapy, for chronic back pain
• autologous chondrocyte implantation and matrix-induced autologous chondrocyte implantation
• vertebroplasty

The References page contains a link to the Health Insurance (General Medical Services Table) Regulations 2014, and the MBS.