The Simple Guide to Billing Under Medicare

Medicare is the universal health scheme that grants Australians, and certain foreigners, access to healthcare services at little to no cost. It’s largely funded by the Medicare levy, which collects 2% of a citizen’s taxable income in the same way income tax is collected. There may be an additional surcharge depending on income amount and level of private coverage.

Basic Medicare benefits include coverage for out-of-hospital services, such as those from a general practitioner or specialist. Basic benefits also include eye checks and services in private hospitals. In limited cases, benefits may also cover child dental care, imaging services, or allied health services. Medicare typically covers 85% of a patient’s healthcare costs, although some providers may accept Medicare for full payment. In these cases, the healthcare provider bills the government, and the patient isn’t charged. Patients also receive free treatment in public hospitals. It’s important to understand the limits of Medicare and how it can be billed.

Purpose and Limitations

Medicare was originally intended to replace private insurance plans for hospital and medical care, although it doesn’t cover some important costs like ambulance services, adult dental, hearing aids, and other services. Costs not covered by Medicare are generally paid by other government programs, by private health insurance, or by individuals.

There have been long-standing disputes between government entities in regard to Medicare. Entities can shift costs to each other by sending patients to different or additional healthcare providers to avoid having to cover the full cost themselves.


Services at public hospitals are billable under Medicare so long as the services weren’t funded under a different arrangement with a government entity. Requirements to bill under Medicare include that the person was treated as a private patient, the service was eligible for Medicare billing, and that any necessary referrals were obtained. The Medicare Service item number will then be billed for services.

Patients are legally responsible for all claims, even if they claim was submitted by another party. All claims are subject to audit, and individuals may have to repay any benefits that were received incorrectly.

In addition to hospital services, patients may be eligible for bulk billing. You’ll need to check to see if your healthcare provider is enrolled in bulk billing beforehand, and if so, you may be able to use Medicare benefits to cover all costs. Bulk billing typically covers regular doctor visits, x-rays and scans, and eye tests. Those with healthcare cards may be able to bill additional services.

Role of Private Insurance

As demonstrated, not all healthcare costs are covered under Medicare, and nearly half of Australians are covered through private health insurance (PHI). These plans often offer rebates for selected services, and they generally grant faster access to elective services. Insurance plans can be purchased to cover additional hospital treatments or additional services. Payment for plans is determined by factors like age, applicable rebates, and Lifetime Health Cover (LHC) rules. Higher premiums are charged to those who don’t have private insurance before age 30. This is meant to encourage individuals to adopt insurance policies early on. Compare health insurance policies to find which program is right for you.

Those with insurance can choose to be treated as a public or private patient. If they incur costs above their Medicare benefits, the patient will typically be responsible for paying the difference. Private insurance opens patients up to multiple new treatment possibilities such as home care, chiropractic services, additional optometry services, hearing tests, hearing aids (see for more information), and more.

Medicare is great for billing general services, and it may suit all patient needs if their providers bill under Medicare. Those with additional needs will likely need to opt for a combination of Medicare and insurance.

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