Billing and Claiming in Obstetric On-Call and Locum Situations

Dr Olivier is an obstetrician who has run a busy practice for several years. She has decided to take a 4-week holiday at the end of the year and would like to engage a locum to look after her patients in that time. Dr Olivier has not done this before and wants to gather some more information about how she and the other doctor would bill her patients and claim from Medicare. She has read a lot about Medicare using new audit techniques lately and wants to make sure she is making the proper arrangements, so she can have a more carefree break.

Q: Can the locum claim from Medicare using my provider number while I am on holiday?

A: No. For all obstetrics items (except items 16400 and 16514), you must personally perform the medical service in order to claim from Medicare under your provider number. You can find an explanation of this in the MBS Explanatory notes, GN.12.30. Therefore, a locum who is performing medical services on your behalf for any period of time, should not claim from Medicare using your provider number as it is not in line with the MBS rules.

Q: Should the locum obtain their own provider number for the work they do on my behalf while I am on holiday?

A: Yes. Where a locum will be in your practice for more than two weeks the locum should apply for a provider number for the relevant location. This also applies if a locum is in your practice on a regular basis, but may work for periods of less than two weeks. If the locum will be working in your practice for less than two weeks and will not be returning there, they may have other options such as using one of their other provider numbers. However, they should contact the Department of Human Services on 132 150 to discuss their options. You can find an explanation of this in the MBS Explanatory notes, GN.2.6.

Q: Does this apply for existing patients where I have provided antenatal care?  Would the locum claim item 16401 (a new consultation) or a 16404 (a review)? The patients will be new to the locum but not to me or the practice.

A: Yes. It applies for all patients regardless of whether they are a new patient or an existing patient. A locum should claim item 16404 as Medicare will treat a locum consultation as a “review” or continuation of a course of treatment, not an initial consultation (item 16401). As you would not claim an item 16401 after seeing the patient after the first time, neither should the locum. If the locum is a not a specialist obstetrician, they are not able to claim item 16404. They would need to claim an MBS attendance item, such as item 23 if they are a GP obstetrician, or item 53 if they are a non-specialist.

Q: Does it also apply to babies being delivered by the locum, even if the locum has not provided any antenatal care?

A: Yes. Items 16515 and 16520 allow for locums to take over the management of the birth where they have not provided antenatal care to the patient. MBS items 16527 and 16528 allow for obstetricians (including locums) to take over the management of the birth where the patient’s care has been transferred by a participating midwife.

Q: Who will receive the Medicare benefit?

A: That is a personal decision for you to work out with your locum. You should both agree to the process through a contract. Generally, the person who claims the benefit using their provider number would receive the benefit. However, the locum should be able to complete a direction to Medicare for the payment of the benefits to you or your practice entity if they agree to do that.  After that, any transfer of money between you and the locum is a matter of your contractual agreement with them. In practice this will mean that:

  1. The locum applies for a provider number for your practice.
  2. The locum authorises Medicare to deposit payments for their billings into your bank account (or the practice account).
  3. You have an arrangement with the locum to pay them a percentage of the billings for the patients they see / bill, which is agreed between you.
  4. You make the payments of the agreed amounts directly to the locums.

Q: Will the Department of Health know if I am overseas?

A: Yes, quite possibly. In December 2019 legislation was passed to allow for data-matching between the Department of Health (which runs Medicare compliance activities, such as audits) and other Australian government agencies, including the Department of Home Affairs. This allows for the matching of Medicare claims data with the immigration data of the doctor and patient. By matching the date of a Medicare claim with a record confirming that the doctor or patient was overseas at the time the claim was made would alert the Department of Health that a benefit may have been wrongfully claimed.

Q: Where can I go for more information about MBS items or questions about locums?

A:  For help with the interpretation of specific item numbers you can e-mail your query to If you require about Medicare claiming generally or how to set up a locum in your practice you can ring the Department of Health’s Provider Enquiry Line on 13 21 50.

Remember, you are legally responsible for the claims made to Medicare under your provider number. By making a claim you are affirming that you understand and have met the requirements under the item descriptor in the MBS.

Call your medical indemnity insurer if you have any additional questions.

Avant members can call Avant’s medico-legal advisory service on 1800 128 268 for medico-legal queries, including questions about Medicare.

NASOG thanks the Avant Mutual Group’s Medico-legal Advisory team for this advice. Developed with input from the Department of Health MBS Policy & Specialist Services Branch.
Version Date: 31 May 2020


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