Billing Medicare in public hospitals

This information will help you understand your legal obligations when billing under Medicare for patients in public hospitals.

Eligibility

  • under the Health Insurance Act 1973, we can't pay a Medicare benefit for a professional service funded under an arrangement with the Australian Government or a state or territory government
  • when you bill under Medicare for services you provide to a patient in a public hospital, make sure you understand and meet the requirements of the Medicare Benefits Schedule (MBS). These include:
    • the patient is an admitted patient
    • the patient elected to be treated as a private patient
    • the patient is eligible for a Medicare benefit
    • the service is eligible and not already funded by other means
    • any necessary referral is valid for Medicare purposes, and
    • the MBS item number is correctly billed for the service you provided

What you need to know

  • if you bill Medicare under your Medicare provider number or in your name, you are legally responsible for that claim, even if the billing was done by hospital administration
  • any claims you have billed under Medicare may be audited
  • you may have to produce documents to verify claims for services you provided to a patient in a public hospital
  • we understand documents for hospital patients are often held by the hospital, rather than you, the practitioner. If necessary, we can issue a notice to produce documents to a third party, such as a hospital administrator
  • if you are audited and your billing under Medicare is found to be non-compliant, you must repay any benefits that have been incorrectly paid. You may also need to pay an administrative penalty. You will be responsible for the repayment regardless of whether the hospital did the billing or received the Medicare benefits on your behalf

How we can help you

We are continuously developing education material to help assist with billing Medicare correctly in public hospitals. This is what is available to you now:

What you need to do

To avoid billing incorrectly, you should:

  • regularly check details of all services billed to Medicare in your name or under your provider number
  • make sure you can substantiate any Medicare claim made under your provider number
  • get independent legal advice if you aren’t sure whether your billing meets legal requirements
  • complete and send us a Voluntary acknowledgement of incorrect payments form (MS002) as soon as possible if you become aware of an incorrect Medicare claim, and
  • regularly check our website for updates and new educational material

For more information

Stay up to date with the MBS and manage your billing by:

Resources

Email medicare.prov@humanservices.gov.au if you have any questions on billing Medicare in public hospitals.

Complete a Voluntary acknowledgement of incorrect payments form (MS002) if you think you have incorrectly claimed a Medicare benefit or received a benefit from Medicare that you are not entitled to.

Contact the Information Release Section to request a 'report of claims for services provided under your Medicare provider number or in your name'.

Email the Australian Government Department of Health hospital.financing@health.gov.au if you have questions about Australian Government funding for public hospitals.

Useful links

Page last updated: 12 February 2016

This information was printed Thursday 29 September 2016 from humanservices.gov.au/health-professionals/subjects/billing-medicare-public-hospitals It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.