RANZCR: Starting Out with Medicare Provider Numbers and Compliance Activities

The Royal Australian and New Zealand College of Radiologists (RANZCR) Inside News Month Year

Compliance with the requirements of the Medicare Benefits Schedule (MBS) is one of many professional practice issues that radiologists must come to grips with when starting clinical practice. But it is one where trouble can often arise.

The Department of Health (the Department) has a strong program aimed at protecting Medicare through the prevention, identification and sanctioning of incorrect claiming, inappropriate practice and fraud. Last year we saw the Department audit radiologists they considered outliers in various billing behaviours, including coclaiming MBS Item 104 with a diagnostic imaging test. This year, there has been an audit to look at the claiming of certain items when also billed with services which require a personal attendance. It is reasonable to expect that similar audits will continue to be undertaken.

We acted for several radiologists whose billings were the subject of the audit into co-claiming Item 104 and we can offer some insights into how new radiologists can minimise the risks of this type of trouble.

Many of the large commercial or corporate radiology practices across Australia employ radiologists on a salary to provide services and it is the practice which bills and collects the benefits.

When a radiologist starts with a practice, they are typically required to provide their provider number to the practice, and they trust the practice’s administrative staff to bill appropriately for the services provided. It is not uncommon for the radiologists to have no idea of what claims are being submitted by the practice and as they are being paid a fixed salary, they may feel little incentive to check. In the cases in which we were involved, we sought and obtained indemnification from the practice involved in respect to the radiologist’s expenses and of any repayment of benefits which may have flowed from submitting incorrect claims. Not all employed radiologists may be so lucky.

To mitigate the risk of incorrect claims being submitted using your provider number, you should:

- read carefully and be very familiar with all of the requirements of the MBS, including the item descriptors and the explanatory notes related to the type of services you are providing

- when entering into an employment agreement with a radiology practice, ensure that the agreement obliges the practice to: give you ready access to the claiming records in respect of the services you provide; indemnify you for the expense which may flow from the practice having submitted incorrect claims

- keep a record of the actual services that you provided

- make a daily or at least weekly practice of double-checking the daily billing records of the practice in respect of the services you provided.

In circumstances where a radiologist is a contractor and is not employed, it is imperative that you are clear on how your provider number will be used when you give it to the practice.

We suggest to clients that at the time of commencing practice as a contractor, radiologists should make a notation alongside of their provider number that it is to be used only in strict accordance with the radiologist’s instructions.

To ensure you are complying with the requirements of the MBS it is critical that you are very careful about what use is made of your provider number.

Andrew Davey

Director Unsworth Legal