Peter Larter, Larter Consulting - Attracting Medicare Benefits to Support Nurse Practitioner Roles...
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Transcript of Peter Larter, Larter Consulting - Attracting Medicare Benefits to Support Nurse Practitioner Roles...
PETER LARTER DIRECTOR, LARTER EDUCATION
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:
• Clinical signs and symptoms
• No obvious underlying cause
82215 $49.80 Professional attendance by a nurse practitioner lasting at least 40
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
Community, Aboriginal Medical Service, ACCHO
82222 $67.15 Attendance, at least 40 mins
Community, Aboriginal Medical Service, ACCHO
82223 $24.10 Attendance, less than 20 mins
Residential aged care
82224 $45.65 Attendance, at least 20 mins
Residential aged care
82225 $67.15 Attendance, at least 40 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
• Provider runs a business
• 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
• Provider runs a business
• Hands over a % of MBS income via a contractual agreement in exchange for rooms, admin support etc.
Rooms for rent
• Provider runs a business
• 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:
• Clinical signs and symptoms
• Easily identifiable underlying cause
82210 $33.80 Professional attendance by a nurse practitioner lasting at least 20
minutes involving:
• Clinical signs and symptoms
• No obvious underlying cause
82215 $49.80 Professional attendance by a nurse practitioner lasting at least 40
minutes involving:
• Multiple clinical signs and symptoms
• Possibility of multiple causes
NP hospital outpatients
would care service1
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
• 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
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
• 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 )
THANK YOU! Questions,
comments? Peter Larter – [email protected]
Presentation © Larter Consulting, 2014.
All rights reserved.