A Comprehensive Guide to Australian Medical Billing
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Admin-Assist
The person financially responsible for the account (e.g., a parent for a child).
Overseas Student/Visitors Health Cover. These require special handling.
The list of fees a doctor charges for their services, which can differ from Medicare or Health Fund rates.
The official report from the surgeon detailing what occurred during a procedure. This is required by insurers for payment.
A request to an insurer for a discretionary, one-off payment for something not normally covered.
To secure a booking and cover the patient's out-of-pocket costs before a procedure.
You receive a Remittance Advice from a third party (e.g., an insurer).
Use the "Organisation Remittance" tool in Gentu for this process.
Medicare is Australia's universal health insurance scheme. It gives all Australians access to healthcare at low or no cost.
When a doctor accepts the Medicare rebate as full payment for a service. The patient has no out-of-pocket cost.
Private Health Insurance (PHI) gives patients more choice, such as their own doctor, shorter wait times, and access to private hospitals.
The doctor accepts the fund's fee as full payment. The patient pays nothing out-of-pocket.
The fund covers most of the fee, and the patient pays a defined out-of-pocket amount (the 'gap').
An IFC is a formal agreement outlining a patient's out-of-pocket costs before a procedure. It's about total transparency.
Protects the patient and the practice from disputes.
Ensures financial agreement before services are rendered.
No surprise bills means happier, more informed patients.
This is one of the most common and costly mistakes. The rule is simple but counter-intuitive.
A doctor can either accept HBF's higher fee schedule (No Gap to the patient) OR charge a gap. The moment a gap is charged, HBF pays the LOWER MBS rate, not their higher schedule.
Getting this wrong causes a Shortfall: a direct loss of income for the doctor.
Comprehensive cover for all clinically necessary conditions. Generally, you can bill directly without prior approval.
Covers only specific, service-related conditions. You MUST get approval before treatment.
When dealing with work-related injuries, we are billing a third-party insurer, not the patient or Medicare. There is one rule that you must never, ever break.
The insurer MUST approve all planned appointments and procedures BEFORE they happen. No approval = No payment.
An assistant can only be billed if the primary surgical item in the MBS has \\\"(Assist.)\\\" in its description.
Laparotomy... for benign disease (including ectopic pregnancy...) not being a service associated with hysterectomy) \\(Anaes.)(Assist.)
If you try to claim an assistant on an ineligible item, you will get an error and the claim will be rejected.
The correct assistant item number depends on the total fee of the main surgical items.
When the aggregate surgical fee is LESS THAN $651.30 (as of Jan 2025).
When the aggregate surgical fee is MORE THAN $651.30 (as of Jan 2025).
\\"Garbage In, Garbage Out.\\" Every detail you enter has a direct impact on cash flow and workload.
Correct claims get paid faster. It's that simple.
Avoids the frustration of chasing rejected claims and re-submitting.
Accurate records are essential for audits and medico-legal integrity.
Incorrect Account Holder information (e.g., child instead of parent).
Wrong Site of Service (e.g., billing telehealth from the hospital).
Incorrect Date of Service.
Missing or expired Referral.
Using Item Numbers that are incorrect or ineligible for the provider.
Is about compliance and risk management. Get it signed, get it paid, get it filed.
Is about attention to detail. The right account type prevents shortfalls.
Is about following the rules. DVA cards and WC approvals have unique workflows.
Is about getting paid correctly the first time. Double-check everything.
What questions do you have?