Peter Larter, Larter Consulting - Attracting Medicare Benefits to Support Nurse Practitioner Roles...

PETER LARTER DIRECTOR, LARTER EDUCATION

[email protected]

How to successfully attract

Medicare Benefits for your

organisation Developing the Role of the Nurse Practitioner Conference, 2014

• Something interesting

about you

• If you could wave a magic

wand to know something

about using Medicare and

be able to apply it

immediately at work, what

would it be?

You and a magic wand

About Medicare

• Medibank from 1975-6, Medibank II

1976-84

• Medicare 1984-99

– Medicare practitioners, optometry,

diagnostic imaging, radiology..

– Stable

About Medicare

• 1999-2010: number of Medicare

items quadrupled

– Nurse practitioner items introduced 2010

About item numbers

• To search for items, google „MBS

online‟ and enter the item number there Item number

Item name

Medicare benefit

• 100% of fee for GP and PN services

• 85% of schedule fee for NP and allied health

Click here for explanatory notes: “The Rules” Schedule fee

Medicare billing

• „Bulk bill‟ – client assigns the Medicare

rebate to the provider

• „Privately bill‟ – client pays full amount up

front, and

– Medicare benefit deposited in their bank account,

or

– Goes to Medicare office to collect benefit

Nurse Practitioner

MBS items

MBS Items (face to face)

Item #

Fee, BB

Item description

82200

$8.20 Professional attendance by a nurse practitioner for an obvious

problem – straightforward, limited examination and management

82205 $17.85 Professional attendance by a nurse practitioner lasting less than 20

minutes involving:

• Clinical signs and symptoms

• Easily identifiable underlying cause

82210 $33.80 Professional attendance by a nurse practitioner lasting at least 20

minutes involving:


• No obvious underlying cause


minutes involving:

• Multiple clinical signs and symptoms

• Possibility of multiple causes

MBS Items (telehealth)

• Items also available since 2011 to

participate in a video consultation with

a specialist or consultant physician

– With the patient, providing clinically

relevant support whilst they are consulted

by a specialist or consultant physician

– At least 15km distance away

– Not for admitted hospital patients

MBS Items (telehealth)

Item #

Fee, BB Item description

82220 $24.10 Attendance, less than 20 mins

Community, Aboriginal Medical Service, ACCHO

82221 $45.65 Attendance, at least 20 mins




82223 $24.10 Attendance, less than 20 mins

Residential aged care





Business models • 4 kinds of models

Feel free to ask those tricky questions…

MBS in public and private

health services • Four kinds of models

100% donation („salaried‟)

• Staff attracts MBS rebate

• MBS is „handed over‟ to employing org

• MBS is income to the staff member, offset by their donation

% split

• Provider runs a business

• Hands over a % of MBS income via a contractual agreement in exchange for rooms, admin support etc.

Rooms for rent


• Rooms rented out to a private provider

• Similar but simpler than % split

Partner with private providers

• Informal or formal partnership with private provider who is offsite

• No need to be involved with MBS billing

NP as private provider

• In both private and public settings, the

NP must

– Register with Medicare Australia as a

private provider - provider number

– Have professional indemnity insurance

– Have collaborative arrangements in place

with a medical practitioner

MBS in public health

services • DISCLAIMER - The content of this presentation constitutes

general information only and should not be relied upon in any

circumstance. Larter Consulting Pty Ltd ABN 16 151 460 927 its

officers, employees, contractors and agents (Larter

Consulting) does not warrant the accuracy of the information

contained in this presentation and it is not intended to be, and

should not be used as, a substitute for professional

advice. Larter Consulting does not provide, or intend to provide,

legal advice. Persons or entities requiring legal advice should

consult a suitably qualified Australian legal practitioner or other

appropriately qualified adviser. Larter Consulting expressly

disclaims all liability for any loss or damage however arising

from reliance upon any information contained in this

presentation.

MBS in public health

services • Health Insurance Act 1973 (Cw) –

direct quotation: s19(2) “Unless the Minister otherwise directs, a

medicare benefit is not payable in respect of a

professional service that has been rendered by, or on

behalf of, or under an arrangement with:

• (a) the Commonwealth;

• (b) a State;

• (c) a local governing body; or

• (d) an authority established by a law of the

Commonwealth, a law of a State or a law of an

internal Territory”.

MBS in public and private

health services • Four kinds of models

100% donation („salaried‟)

• Staff attracts MBS rebate

• MBS is „handed over‟ to employing org

• MBS is income to the staff member, offset by their donation

% split


• Hands over a % of MBS income via a contractual agreement in exchange for rooms, admin support etc.

Rooms for rent


• Rooms rented out to a private provider

• Similar but simpler than % split

Partner with private providers

• Informal or formal partnership with private provider who is offsite

• No need to be involved with MBS billing

100% donation model

• Some legal ambiguity for others

• s19(2) exemption in public rural health

services with communities of <7,000

persons

• Some health services allow private

practice arrangements for employees,

mandating that MBS fees generated

are handed back to them, and they

pay a private practice component

100% donation model

100% donation model

• Seek legal & HR advice

• Inform and consult staff

• At end of financial year, provide clinicians with

a statement of MBS income that they „handed

over‟ for their tax purposes

• Amend employment contracts

• May need to establish a „craft group‟

% split & rooms for rent

models • External private providers OR existing staff

have rights of private practice but keep a

proportion of the MBS revenue

• Contract should consider

– How provider is paid, and amount

– Billing and administrative arrangements

– Shared or independent client records

– Other expectations e.g. CPD, meeting attendance

– Insurances

– etc.

External private providers

model

• Very unlikely NP model, but possible.. Usually

a demand management strategy or quality

improvement strategy

Model acceptability

• 100% donation model

– Legal and HR complexity for organisations

– More admin/clinical control for organisations

– Most palatable to most NPs

• % split and rooms for rent models

– Easier for organisations to administer

– NPs take more financial and clinical risk

Model viability and

sustainability

Financial viability

• KPMG1 for Dept Health WA undertook nurse

practitioner MBS business modelling

1. Department of Health, Western Australia. 2011. Nurse practitioner business models and

arrangements.

http://www.nursing.health.wa.gov.au/docs/reports/business_models_arrangements.pdf

• MBS is activity-based funding and is most

“financially rewarding” for high, consistent

throughput

• Some NP models fit this bill, some don‟t.

• Bulk-billed MBS NP models will never be

financially viable under current MBS– private

billing could be


Modelling assumptions

• Full time equivalent working 201 days a year

– 365-125 weekends – 10 CPD – 20 annual leave –

9 personal leave

• Mix of consultation-based item numbers only

(not telehealth support)

• NP salary $94,000 + 15% oncosts + 20%

corporate charge

• 100% bulk billing

MBS Items (face to face)

Item #

Fee, BB

Item description

82200

$8.20 Professional attendance by a nurse practitioner for an obvious

problem – straightforward, limited examination and management

82205 $17.85 Professional attendance by a nurse practitioner lasting less than 20

minutes involving:


• Easily identifiable underlying cause


minutes involving:


• No obvious underlying cause


minutes involving:

• Multiple clinical signs and symptoms

• Possibility of multiple causes

NP hospital outpatients

would care service1


arrangements.


• 24 patients per 8 hour session – 6x15min,

16x20 min, 1x30 min, 1x45 min (some

clinical, some admin)

• Not financially viable without private billing or

other subsidy, but provides substantial income

• INCOME: $584.08 per day over 201 working

days = $117,504

• EXPENSE: $94,000 + 43% (13% oncosts +

30% corporate charge) = $134,420


NP rural/remote outreach

model, not s19(2) exempt


arrangements.


• 5 patients per 8 hour session – 1x15min,

1x20 min, 1x30 min, 3x45 min +

• Similar story – not viable under MBS in any

circumstances

• E.g. if charging higher MBS rebates,

INCOME: $119.30 per day = $23,979

EXPENSE: $134,420

• Community nursing, with significant travel,

providing holistic care which can take >60 mins


NP rural/remote outreach

model, not s19(2) exempt

e.g. #700-#715 – health assessments by nurses

“for an on behalf of a general practitioner” may

provide additional MBS income

• If the nurse practitioner is employed by or

retained by a general practice, they can attract

additional Medicare Benefits which go to the GP

and could ultimately support the NP‟s

employment (though may not be professionally

ideal)

Thinking and

discussion break

1. What sort of model may best suit your

organisation?

2. Is there anything unclear about the four

models?

3. Project planning – what would some of the

steps be, and who would need to be

involved?

Project planning

Project planning

Project Advisory Group (PAG)

AA, Project Sponsor (e.g. CEO) BB, Senior Program Manager CC, Clinician representative

DD, Quality & Risk Coordinator EE, Finance team FF, Administrative team GG, Medicare Local representative

Project sponsor

(e.g. CEO)

Project manager /

project officer

Project Advisory Group

Conclusions

• MBS won‟t fully pay for a service without

– Private billing (non-bulk billing), and/or further

public subsidy

– Efficient and reliable billing and administrative

systems

– Reliable & minimum level of throughput

• Difficult to make a model sustainable if

– the NP workforce is not convinced about HR

arrangements required to make it happen

– Other parts of workforce don‟t understand MBS or

won‟t take on more roles

Final point

• MBS models are complex and require a

complex project with effective governance,

knowledge and communication to make it

happen

• See supplied “MBS Checklist” for an example

of the process that community health services

undertake

Lessons from the field

• Two key resources

– Dept. of Health, Western Australia. 2011. Nurse

practitioner business models and arrangements.

http://www.nursing.health.wa.gov.au/docs/reports/

business_models_arrangements.pdf See „Lessons

– „Lessons Learned‟ document – Victorian

community health service MBS implementation

(provided and

http://www.health.vic.gov.au/pch/downloads/lesson

s_learned.pdf )



http://www.health.vic.gov.au/pch/downloads/lessons_learned.pdf

http://www.health.vic.gov.au/pch/downloads/lessons_learned.pdf

Peter Larter, Larter Consulting - Attracting Medicare Benefits to Support Nurse Practitioner Roles...

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