Medicare billing law and practice: Complex, incomprehensible and beginning to unravel

Abstract

Australia’s Medicare is still widely considered one of the world’s best health systems. However, continual political tinkering for forty years has led to a medical billing and payment system that has become labyrinthine in its complexity and is more vulnerable to abuse now, from all stakeholders, than when first introduced. Continuing to make alterations to Medicare without addressing underlying structural issues, may compound Australia’s health reform challenges, increase the incidence of non-compliance and expenditure and thwart necessary reforms to develop a modern, data driven, digitally informed health system. For the medical practitioners who are required to navigate the increasing complexity and relentless change, they will remain at high risk of investigation and prosecution in what has become an anarchic operating environment that they cannot avoid, but do not understand.

The legitimacy of the nurse practitioner as a non-medical surgical assistant: Historical evidence from Australia

“…The MBS provides information for payment of Medicare benefits and is not the law but rather the Government's interpretation of the Health Insurance Act (HIA) 1973 (Australian Government, 2019b;Faux et al, 2019). The MBS relies not only on the HIA 1973 legislation but also the National Health Act 1953 along with many Regulations and Determinations for payments of Medicare benefits.…”

“…At the introduction of Medicare, eligible providers of medical services included Medical Practitioners, dentists, and optometrists (Parliament of Australia, 1973). The inclusion of optometrists demonstrates that, even at the inception of Medicare, the intent was to allow broader access by healthcare professionals to perform medical services, not just Medical Practitioners and this notion is demonstrated today with services provided by various allied health professional and nurses (Faux et al, 2019). Similarly, the term medical services are not limited to Medical Practitioner as some items on the current MBS are outside the skill set or education of the Medical Practitioner.…”

“…Similarly, the term medical services are not limited to Medical Practitioner as some items on the current MBS are outside the skill set or education of the Medical Practitioner. An example of this is the skill set of a speech pathologist whose practice is not within the bounds of a medical practitioner's practice (Australian Government Department of Health, 2017b;Faux et al, 2019).…”

“…To implement Section 51 (xxiiiA) the High Court of Australia ruled the Health Insurance Act (HIA) 1973 a law about the provision of medical and dental servicses; however, the Act does not cite the phrase "medical and dental services" but repeatedly uses the term "professional services". While the reasoning for this remains undetermined, it is suggested that a medical service has a broader meaning than a service undertaken solely by a Medical Practitioner (Faux et al, 2019;Wilde, 2005).…”

“…While it may be considered that the NP is an autonomous practitioner and shouldn't be under the supervision of the surgeon; the salient point here is that, if the NP is too autonomous for the role why is a patient rebate restricted to Medical Practitioners who might also be too autonomous? As outlined in the HIA 1973 Section 3 and explained by Faux et al (2019), clinically relevant services must also be necessary. This ensures that healthcare practitioners can tailor care to individual patients' needs and alludes to the Health Practitioner National Law (Qld) Part 1 Section 3 which outlines the need to facilitate access, and enable a flexible and responsive workforce (Australian Government, 2019a).…”