Medicare Billing for Private Outpatients Policy

Version 4.0 Approved 6 October 2022 

The Medicare Billing for Private Outpatients Policy (PDF 550KB) provides the mandatory requirements and obligations for participating medical practitioners seeking to bill private outpatient services to the Commonwealth (Medicare) through exercising Rights of Private Practice (ROPP) in accordance with:

  • the 2020-25 National Health Reform Agreement (NHRA) and its business rules, including those relating to specialists billing under Rights of Private Practice (ROPP)
  • legislative requirements as defined by the Health Insurance Act 1973 and
  • the Medicare Benefits Schedule (MBS).

This policy has been developed in consultation with the Commonwealth Department of Health and Ageing to reflect agreed principles and practices that constitute compliant billing activity, in addition to this policy a best practice Medicare billing for private outpatients’ guideline has been developed to assist medical practitioners in the application of this policy.

Applicability

This policy applies to all employees of SA Health involved in the Medicare billing of outpatient services. This includes employees and contracted staff of the Department for Health and Wellbeing, Local Health Networks (including state-wide services aligned with those Networks) and SA Ambulance Service.

Where a medical practitioner intends to provide private outpatient services, a formal ROPP agreement must be in place with the LHN in which they intend to provide private outpatient services before private services may be offered. This applies where the medical practitioner is employed full time by SA Health or is employed part time and the services are rendered within the scope of SA Health employment.

Private practice billing must be performed in accordance with the ROPP agreement. Professional services provided under ROPP include specialist outpatient consultations, procedures and associated diagnostic services such as pathology and radiology.

Professional services rendered by a medical specialist pursuant to their Rights of Private Practice are rendered under a contract between the medical practitioner and the patient, and not by, or on behalf of or under an arrangement with the State.

Where the Specialist engages in private practice the Specialist shall be indemnified under and in accordance with the Department's Professional Indemnity (Medical Malpractice) Program ("Program") against any description of civil liability whatsoever (subject to the exceptions specified in the Program) incurred by the Specialist in connection with the conduct of private practice by the Specialist whether or not the Specialist continues to be employed by the Employing Authority at the time that they are notified of any claim leading to such civil liability.