Medicare Billing in relation to Health and Allied Health Professional.

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General practitioners (GPs) mostly bill Medicare for their professional fees based on the number and type of consultations. However, GPs and other health professionals that are eligible to access Medicare benefits are required to comply with the appropriate Medicare billing system under relevant legislation(s). Otherwise, this may result in criminal liability. The case of Bajpe and Medicare Participation Review Committee, Re1 demonstrate this points. The brief fact of this case is as follows.

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Dr Bajpe is a registered medical practitioner and operates a solo general practice in Bendigo in Australia. Following a report, by a staff of suspected improper billing under Medicare scheme, Medicare Australia investigated Dr Bajpe in January 2003 and subsequently advised the medical practitioner of his obligation to comply with the Medicare Benefits' Scheme (MBS) Guidelines. However, the improper billing continued until October 2003.

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Amongst other things, Dr Bajpe gave Medicare four provider numbers, suggesting that he practiced in four different areas. However, he only worked at two practices. In his defence, Dr Bajpe argued that he had instructed his practice manager to inform Medicare. However, he failed to follow up with his practice manager regarding it. Also, there were no records of Dr Bajpe having consultation with patient on a particular date for which he claimed a fee. Further, he did not perform some services after hours, which he had billed for, contrary to his claim. His defence was that he had a different understanding of emergency service as opposed to the definition under Medicare.

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Nevertheless, the County Court convicted of obtaining a financial advantage by deception contrary to ss. 134(1) of the Criminal Code Act 1995. Consequently, the Medicare Participation Review Committee disqualified Dr Bajpe from billing under the Medicare scheme for 26 weeks. Dr Bajpe's appeal of the MPRC decision to the Administrative Appeals Tribunal failed.

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This case show that GPs must strictly comply with Medicare billing system to avoid criminal liability, especially the offence of obtaining a financial advantage by deception.2 Furthermore, breach of Medicare billing standards can also result in the disqualification of a GP from participating in billing under the Medicare scheme over a long period of time. During the period of disqualification, Medicare benefits will not be paid for services rendered or initiated by the GP. Furthermore, a detailed record-keeping of all the transactions in the practice is a fundamental obligation required of medical practitioners. A detailed record keeping takes on additional significance during audit and investigations by regulatory bodies.

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Another case that highlights the importance of compliance with the Medicare billing system is the case of Selia v Commonwealth of Australia.3

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The applicant, Dr Selia, is a dentist who operated a dental practice in New South Wales. In October 2014, the Professional Service Review Committee No 812 (PSRC)4 found the applicant to have engaged in inappropriate practices. The inappropriate practices included billing Medicare for dental services prior to providing the service; provision of dental services by other dentists employed by him using his Medicare provider number; failure to provide appropriate level of clinical input into Medicare Benefits Schedule items; and maintenance of records that lacked essential clinical information.

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Based on the PSRC's findings, the Determining Authority5 directed that Dr Selia be reprimanded and counselled. In addition, he was asked to refund the sum of AU$1,129,167.20 to the Commonwealth of Australia. Dr Selia's application for judicial review to the Federal Court of Australia was dismissed.

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This case also emphasises the importance of detailed and up-to-date clinical records in the management of patient care. According to the PSRC, the expectation from the general body of Dentists is that a dentist should familiarise herself or himself with the requirements under the Medicare scheme, especially when engaged in a substantial enterprise.6 Specifically, in the instant case, the inadequacies of the Dentist's clinical records negatively affected his ability to provide effective and good care to his patients.7

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The court also established the principle that poor record keeping could amount to an inappropriate practice.8 Another principle established in this case is that there is no entitlement for payment for Medicare until a service is rendered.9

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The two cases discussed in this article emphasise the importance of compliance with the Medicare billing system by GPs and other relevant health professionals who are entitled to claim under Medicare.

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DISCLAIMER

This article does not create a Client/Attorney relationship neither is it a legal advice. The information contained in this article is for information purposes only. Readers are advised to seek from qualified Legal Practitioners, legal counselling to any questions or concerns arising from their specific factual situation. You can reach Solomons Legal at info@solomonslegal.com.au or +61 7 3117 9433.

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1 (2010) 115 ALD 95

2 This is an offence that is criminalised under s 134(1) of the Criminal Code Act 1995 (Cth).

3 [2017] FCA 7; Federal Court of Australia, per Perry J

4 This body is established pursuant to s 93 of the Health Insurance Act 1973 (Cth)

5 The Determining Authority is established pursuant to s 106Q of the Health Insurance Act 1973.

6 Pg. 18, para 50.

7 Pg 24, para 67

8 Para 84

9 Para 162