If we were to ask health professionals to make a list of administrative tasks that require the most time and effort, chances are that billing Medicare for services provided would figure in the top five.

With that in mind, we are here to support our practicing members with a few pointers on how to reduce the likelihood of Medicare rejections.

There are several reasons why billing Medicare can be an error-prone process:

  • Medicare billing is a complex landscape made up of extremely complicated rules. It often requires an in-depth knowledge of medical terminology, anatomy, physiology, disease processes and analytical skills. And there is a small forest of paperwork and infinite patience involved.
  • Under the Health Insurance Act 1973, all healthcare professionals are legally responsible for services billed to Medicare under their Medicare provider number or name. This puts tremendous pressure on practitioners to make sure they submit accurate claims when requesting payment for Medicare-covered health care items and services.
  • Law, rules and regulations concerning medical insurance billing are very complicated and misunderstanding these can lead to situations that incite investigations regarding insurance fraud. This is exacerbated by the fact that services listed in the Medicare Benefits Schedule (MBS) must also be rendered according to the provisions of the relevant Commonwealth, state and territory laws.

With so much to navigate through, here’s a breakdown of our most common reasons for claim rejection and what you can do to avoid them:

Issue: Medicare cannot accurately identify the patient
Reason for rejection: Insufficient/inaccurate Medicare card details
Rejection codes: 429, 211, 320, 372, 374
Actions to reduce rejection:
  • Ensure correct spelling of the patients name and date of birth
  • Ensure correct allocation of the sub-numerate (the number next to the patient’s name – on the Medicare Card)
  • Check Medicare details are up to date through ECLIPSE or by calling department of Human Services on 132 150, prior to invoicing the insurer
  • Make sure the patient’s Medicare card is green (patients that are not permanent residents cannot be claimed from the insurer unless on overseas visitor health cover)
Issue: Referral details are out of date or incorrect
Reason for rejection: Issues with details from referring providers
Rejection codes: 378, 404, 605, 606
Actions to reduce rejection:
  • Ensure you check the referring provider’s Medicare number from the referral letter and not just rely on your practice software (they may have moved or been issued with a new number)
  • Check you are providing services within the referral period of the original referral – otherwise request a new referral
  • Make sure all specialist referred consultations and those surgical interventions with a specialist specific MBS code are submitted with referral details
Issue: Referral details are out of date or incorrect
Reason for rejection: The referral period does not match the referrer's speciality
Rejection code: 732
Actions to reduce rejection:

Ensure that the referral periods align with the referring practitioner’s speciality. A referral from a specialist is valid for 3 months or less. Referrals exceeding 3 months can only be used by GPs.

Issue: Aftercare invoicing
Reason for rejection: Consult provided in aftercare period
Rejection code: 252
Actions to reduce rejection:

The invoice must be endorsed with ‘Not Normal Aftercare’, when a consultation provided during the aftercare period is for an unrelated reason.  If the consult relates to the aftercare period, then no benefit may be payable.

Issue: Additional information required after partial payment
Reason for rejection: An associated item has been paid and more information is requested
Rejection code: 159, 179, 162
Actions to reduce rejection: Provide the following as appropriate (varies according to item being claimed):
  • start and finish times (for multiple attendances/interventions on the same day)
  • body part/site information (when multiple interventions have been performed on different parts of the body)
  • surgical approach (when multiple surgical approaches are used, such as laparoscopic and endoscopic)
Issue: Item claim limit exceeded
Reason for rejection: The maximum number of claims for the item within a certain period has been exceeded
Rejection code: 160
Actions to reduce rejection:

Check if there is a cap on the number of times the item can be claimed by logging on to HPOS: https://www.humanservices.gov.au/health-professionals/services/medicare/hpos

Issue: Further evidence required
Reason for rejection: Pre-approval not obtained
Rejection code: 416
Actions to reduce rejection: When the Medicare item descriptor includes the words ‘where it can be demonstrated’, you must ensure you have pre-approval from Medicare before claiming through the insurer.

 

 

Disclaimer: This publication is not comprehensive and does not constitute legal advice. The information contained within is general information and should not be considered as a substitute for obtaining professional advice. You should consider your individual circumstances before relying on any content. While we endeavour to ensure that information is as current as possible at the time of preparation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently. Avant Mutual Group Limited and its subsidiaries will not be liable for any loss or damage, however caused (including through negligence), that may be directly or indirectly suffered by you or anyone else in connection with the use of information provided in this document.