Locum cover led to Medicare audit

For many doctors, concern about who will look after their patients if they go away is a major barrier to taking time off.

If you arrange for a locum to ensure continuity of care for your patients, it’s important to be clear on the billing arrangements.

Recently we were contacted by one of our members who found himself the subject of a time-consuming and costly Medicare compliance audit.

The specialist physician had done the right thing for his patients by arranging a locum consultant of the same specialty to provide cover while on holiday overseas. What he and his locum hadn’t realised was that, although his colleague was only covering for a few weeks, all billing of his patients seen by the locum needed to go through a new provider number specific to the locum for the practice location. Instead, the practice manager had submitted claims to Medicare using our member’s provider number.

Government departments sharing data

The issue came to light through a data-sharing arrangement between the Department of Health and Aged Care and the Department of Home Affairs. This picked up that MBS claims had been made to Medicare under our member’s provider number, when passport office records showed he was overseas.

As data sharing between government departments increases, we’re seeing a growing number of members contacting us concerned that they have unknowingly done the wrong thing and their billings are now being audited by Medicare.

In this case, the member was invited to voluntarily repay the MBS services billed, before a debt and administrative penalty was found against him. Despite the good care his patients received from the locum, all the Medicare payments had to be refunded. We were able to support him to make sure no further penalties were applied.

Only bill for services you provide

Members are reminded that the rules around MBS billing are clear. Locum arrangements are designed such that the locum takes over the care of your patients and personally bills for the services provided. One practitioner’s consultation cannot be billed under another practitioner’s provider number, even when providing short-term locum cover.

You cannot bill Medicare when you (or your patient) are out of Australia.

In summary

Practitioners utilising a locum to cover when going on leave should ensure their locum has arranged a provider number or made arrangements with the department before they leave.

They should also ensure staff and the locum are aware not to use their provider number.

Data matching laws

Data matching laws passed in late 2019 gave the Department of Health and Aged Care power to match data across various agencies, one of which is Home Affairs. 

The intention of matching to this particular dataset was provided as a practical example of what can be identified in the Data Matching Notice issued by the department:
“Matching the dates of MBS claims made by a health provider, to Home Affairs records can help determine if a health provider or patient was outside of Australia at the time of the MBS service. This will assist in identifying instances where a health provider may have fraudulently claimed Medicare benefits for services which were not validly provided.”

Provider numbers for locums*
Situation	Requirement
Placement at a particular practice will be for two weeks or more.	Locum should apply to Services Australia for a provider number for that location.
Placement at a particular practice will be for less than two weeks at one time, but is expected to occur on a regular basis.	Locum should apply to Services Australia for a provider number for that location.
Placement at a particular practice will be for less than two weeks and is not anticipated to recur.	Locum should contact Services Australia to discuss options. (They may be permitted to use one of their other provider numbers.)
Relieving a specialist but does not hold specialist registration.	Locum cannot claim Medicare benefits at the specialist rates.

*MBS Online, Medical Benefits Schedule General Explanatory Note GN.2.6

This article was originally published in Connect magazine issue 23.

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