Medicare vs Private Health Fund Billing
For eligible private inpatient medical services, Medicare and private health insurance can both contribute to the same medical account. This is one reason inpatient medical billing requires more specialised administration than routine outpatient billing.
The 75% / 25% MBS framework
The Australian Government states that Medicare covers 75% of the MBS fee for eligible in-hospital doctor and specialist services and private health insurance covers at least 25%. The doctor's actual fee may be higher than the MBS fee, which is where gap arrangements become important. Department of Health: hospital cover and medical services.
The MBS fee is not necessarily the doctor's fee
The Medicare Benefits Schedule fee is a reference fee used to calculate Medicare benefits. Doctors can set their own fees. If the total fee is above the combined Medicare and insurer benefit, the patient may have an out-of-pocket amount unless a no-gap or known-gap arrangement changes the payable amount.
How ECLIPSE simplifies the process
Services Australia says ECLIPSE can submit Simplified Billing claims and inpatient patient claims. Billing agents can submit applicable claims involving Medicare and participating private insurers. Services Australia: ECLIPSE.
DEVZ's role
DEVZ manages the administrative billing workflow using our own Medicare- and ECLIPSE-compliant software. Medicare and health fund payments are directed to the doctor's nominated account; DEVZ does not pool the doctor's medical income.
Frequently asked questions
Does Medicare pay 75% of every hospital bill?
No. The 75% figure relates to eligible in-hospital medical services and the MBS fee, not every hospital charge.
What does private health insurance pay?
For eligible in-hospital medical services, private health insurance covers at least 25% of the MBS fee, subject to the policy and claiming rules.
What happens if the doctor charges above the combined benefit?
The difference may become an out-of-pocket gap unless an applicable no-gap or known-gap arrangement reduces or removes it.
Need billing support?
DEVZ Solutions specialises in inpatient medical billing and can also manage outpatient, private and bulk-billed specialist work when required.
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