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Medicare urgent after-hours attendance items – what you need to know

David Pakchung, MBBS (Syd) MHA (UNSW) GCAppLaw (Qld) CertIT DipRACOG AssocDipAppSc (Ambulance), FRACMA, Head of Claims (QLD), Avant

Monday, 4 September 2023

Overnight hours

For many years, claiming urgent after-hours consultation Medicare Benefits Schedule (MBS) items has repeatedly been a focus of review by the Department of Health and Aged Care.

The Department’s latest review of urgent after-hours GP attendance items found a considerable number of GPs had a high ratio of urgent to non-urgent after-hours items, relative to their peers.

As part of its ‘early intervention initiative,’ the Department has implemented comprehensive compliance approaches. These range from so-called ‘light touch’ interventions such as provider education and targeted letters, through to audits and investigations.

Navigating the complex requirements

While a high proportion of urgent to non-urgent after-hours consultation items may be explicable, it is likely to result in compliance scrutiny.

If urgent after-hours items are being claimed under your provider number, the Department will request an explanation of any irregular claiming patterns. You will also be responsible for any repayment of benefits or other outcomes due to compliance action.

Therefore, if you provide after-hours consultation services, it’s essential to correctly select the MBS item number for the service and to adequately document the information relevant to the service and your selection of item number.

Here’s a guide to help you navigate the complex requirements for urgent-after hours attendance.

When can you claim

The MBS urgent after-hours GP items may be used when you determine, from the information available, your patient’s medical condition requires urgent assessment during the unbroken after-hours period. You must have formed an opinion the assessment cannot be delayed until the start of the next in-hours period. It’s essential to consider and record the information you have about the patient’s condition and the time you are considering it.

When claiming urgent after-hours items, you also need to ensure:

  • Your attendance is requested by the patient or responsible person on behalf of the patient, including a spouse, parent, carer, or guardian. This does not include yourself, an employee, or a call centre or reception service.
  • The request is made during the same after-hours period.
  • An urgent assessment is required. You may rely on information conveyed by the patient or the patient’s carer, health professionals or emergency services personnel, but you must decide if an urgent assessment is required by yourself.
  • You attend the patient at their location or reopen the practice rooms.

You record your assessment in relation to the necessity of the attendance in the patient’s medical record, in addition to other relevant clinical information.

When can’t you claim

The Department specifies you can’t claim urgent after-hours items if your patient or responsible person makes a request before the start of the after-hours period, or the attendance occurs outside the after-hours period. You also can’t claim if:

  • More than one patient is seen at the same time (item 594 should be claimed in these circumstances).
  • You routinely provide services to patients in the after-hours periods for a general practice or clinic that routinely provides services to patients in after-hours periods.
  • An urgent assessment has not been done by you prior to the consultation, or the patient's condition is determined not to be urgent.

What items to use and at what times


MBS chart

Source MBS online

When you provide after-hours home visits, you should bill the non-urgent items unless all the requirements for the urgent items are fulfilled.

Useful resources

Disclaimers


IMPORTANT:
This article is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on its content, and practise proper clinical decision making with regard to the individual circumstances. Persons implementing any recommendations contained in this article must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.

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