Addressing variations in billing of medical consultations

The Australian Government is introducing changes to claiming rules for certain Medicare Benefits Schedule (MBS) items to address the variations in billing of consultation items by some providers. The changes will help to ensure that patients receiving the same type of service from different doctors receive the same Medicare rebates.

Page last updated: 28 November 2017

Addressing variations in billing of medical consultations (PDF 69 KB)

What are the changes?

The Taskforce was concerned about the practice of co-claiming, where an attendance or consultation item is routinely added to a procedural item when there is no substantive ‘attendance’ component of the service. MBS data indicates that some doctors routinely add a consultation item to a patient’s bill on the same day as a procedure which has been planned some time in advance. In these instances, the ‘consultation’ is considered to be integral to the procedure and is not a separate service. Doctors on the Taskforce who have reviewed this issue strongly recommend that this practice is unreasonable.

For example, a referral for a colonoscopy involves extensive preparation for the procedure by the patient, and the patient should have been appropriately assessed and provided consent before they are scheduled for the procedure.

MBS data show that some providers never or very rarely bill a consultation item with a colonoscopy or other operation, while others will often (or always) bill a consultation item for the same procedure. This variation in billing means that patients are receiving different amounts of MBS benefits for the same procedure.

Billing unnecessary consultation items can lead to increased out-of-pocket costs for patients with no added clinical benefit. For most specialist consultations, there are no requirements around how long a doctor should spend with the patient, or what services are expected to be provided. This means that there is some confusion about when a consultation can be billed.

To address the current uncertainty the Government has decided to prohibit the billing of ‘follow-up’ consultation items on the same day as a significant procedure (which is one which has an MBS fee equal to or greater than $300).

The changes will commence on 1 November 2017.

Why are these changes being made?

Changes to the claiming of consultations with procedures were recommended by the MBS Review Taskforce following an extensive period of public consultation.

The Taskforce is conducting an independent, clinician-led review, which makes recommendations to the Government on how the MBS can be modernised to improve patient health outcomes and safety, support equity of access and reduce waste.

Are there any exceptions?

Yes, there are circumstances where it is appropriate to bill a consultation with a procedure and this will continue to be allowed. For example, a surgeon may see a patient for a routine follow-up consultation and later that day perform an unscheduled appendectomy on that patient, where the decision to perform the appendectomy is made during the consultation. It will still be permitted to claim a consultation with a procedure in cases like these. In these extenuating circumstances, practitioners will claim one of the new consultation items (111, 117 and 120) that will be introduced to support these changes.

Patients living in rural locations will not be disadvantaged by this change as long as the procedure was unpredicted and otherwise unscheduled.

What does this mean for patients?

These changes will improve consistency of the MBS benefits paid to patients for the same service. It is anticipated that patients will not be affected, unless a specialist chooses to charge the patient an additional cost to compensate for the unclaimed consultation.

What does this mean for providers?

GP attendances will not be affected by these changes. Doctors will be able to bill a consultation on the same day as performing a procedure when it is clinically appropriate.

Specialists who routinely co-claim consultations with procedures will see a reduction in MBS benefits paid for the services they provide.

Further details on all the changes can be found on MBS Online website.