Medicare is one of the things Australian’s are most proud of, and rightfully so. What’s not to like about publicly funded, high quality universal health care? But Medicare can be confusing and complex for the uninitiated, with lots of different claiming options and associated rules. We deal with these kinds of questions everyday at Medipass, and so in light of our new Medicare integration with Cliniko, we wanted to share an introduction to Medicare claiming, specifically for allied health providers.
How big is Medicare claiming?
The Department of Human Services (AU) has a wealth of information on Medicare claiming, spanning spending, volumes, patient demographics and more. Click here to delve into these statistics.
Interestingly, the top claimants types, by service counts, were:
- Psychologists, including Clinical Psychologists with 5.2 millions claims
- Podiatrists with over 3.2 million claims
- Aboriginal health and Torres Strait Islander health practitioners with over 2.55 million claims, and
- Physiotherapists with over 2.5 million claims
Who is eligible to claim Medicare benefits?
While there are different rules for different conditions, most patients require a valid referral from a GP or Medical Specialist in order to claim for an allied health service. Referrals issued under the following schemes allow allied health providers and their patients to claim Medicare benefits:
- Chronic Disease Management (CDM) — formerly Enhanced Primary Care/EPC
- Focused Psychological Strategies (FPS), including the Better Access initiative
- Pregnancy Support Counselling
- Group Allied Health Services for People with Type 2 Diabetes
- Allied Health Services for people of Aboriginal or Torres Strait Islander descent
- Children with Autism, Pervasive Developmental Disorder (PDD), including the Better Start program
- Patients with Anorexia Nervosa and other eating disorders, from November 2019
Depending on the scheme, the following professions may qualify to raise claims:
- Aboriginal and Torres Strait Islander health practitioners
- Aboriginal health workers
- Diabetes educators
- Exercise physiologists
- Mental health workers, including social workers
- Occupational therapists
- Speech pathologists
Further information on these schemes can be found here.
Bulk bill or patient claim?
It’s your choice as a provider whether your process bulk bill claims, patient claims, or a combination of both.
Bulk billing means the patient assigns their right to a Medicare benefit to you. In other words, Medicare pays you directly, instead of the patient. The patient doesn’t pay anything out of pocket, and Medicare pays you after you have submitted the claim on the patient’s behalf. However, bulk bill claims have a rate cap and providers cannot charge over this cap. For example, a physiotherapy session for Chronic Disease Management (CDM) typically pays the provider $53.80.
Patient claims (PCI) are when the patient or a claimant (e.g., a parent) pays you for the full amount of the service, and you lodge a Medicare claim on their behalf. If the claim is accepted, Medicare will pay the designated amount directly to the patient or claimant. It’s up to you what you charge for a patient claim service — there is no rate cap. For example, a physiotherapy session for CDM where the provider charges $100, the patient will pay the provider $100 and typically receive a benefit from Medicare of $53.80.
Overall, 86% of all Medicare claims are bulk billed. However, we have found that for allied health professionals the percentage of bulk bill claims is closer to 65%.
How do I claim from Medicare?
There are four main channels used by health professionals for Medicare (AU) claims:
- PRODA: Medicare’s own online web portal which allows providers to submit and manage claims. PRODA is free and supports most claim scenarios for allied health professionals. However, PRODA does not integrate with practice management systems and does not process patient/claimant payment cards. Many providers report a non-intuitive lodgement and complex reconciliation experience.
- Medicare Online: This is the channel used to process Medicare claims via another software program, including from within your practice management software. Medicare Online supports all allied health claiming scenarios except for Medicare reciprocal country claims. Medipass’ Medicare solution leverages Medicare Online.
- Easyclaim: Medicare claims processed via a physical terminal, such as those offered by HICAPS, CBA, ANZ or Tyro. Many Easyclaim terminals integrate with practice management systems and most terminals can also process customer card payments. However, Easyclaim does not support all claim types permitted by other channels, such as telehealth claiming, exception referrals, hospital in-patient services or DVA claims. Easyclaim does not provide integrated reporting on bulk bill claim status and related settlement.
- Eclipse: Eclipse is an electronic claiming channel that is typically used for hospital in-patient (admitted) claims and is always initiated from a practice management or hospital management system. Although Eclipse supports allied health claims, it is more typically used by hospitals and medical specialists for in-patient, imaging, pathology and other diagnostic service scenarios.
It’s difficult for a patient to pay and claim for Telehealth services. Currently, common processes include:
- A bulk bill claim is processed via the provider’s practice management software. The patient provides their Medicare card details either over the phone or during the telehealth consult
- Patient claims are processed fully out of pocket where the patient provides their credit card details either over the phone or during the telehealth consult and an invoice is emailed to them to claim back with Medicare
- The patient is emailed an invoice to pay via direct transfer or similar
The Medipass claiming experience is entirely online. Because Medipass doesn’t rely on hardware or terminals to process Medicare claims or out of pocket fees, it’s a perfect solution for telehealth consult claiming. Patients no longer have to manually claim with Medicare using an invoice, and it also means that there is less of an administrative burden (and you avoid potential security risks) in taking the patient’s credit card details.
When do I get paid?
When submitted during Medicare business hours, over 92% of all valid Medicare claims are approved in real-time. The remainder require Medicare review and potentially a clarification from the patient or provider. Once approved, Medicare will usually issue the benefit payment by the next business day.
For patient claims, you are paid by the patient/claimant, which could happen immediately if you accept cash. Although this means that patients/claimants are out of pocket for the entire amount, many will see a benefit payment from Medicare that same day.
If you make a successful bulk bill claim prior to 9pm Canberra time on a Medicare business day, a payment will usually be issued to you by Medicare the following business day. Claims made Saturday, Sunday and public holidays are considered as processed the following business day.
This Medicare guide was originally published on the Medipass website.
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