What is bulk billing?

To talk about bulk billing, we first need to understand what it is. It may sound obvious, but many times I come across people who just don’t know what it really means.

Bulk billing is when a registered provider accepts the Medicare rebate as full payment of the services rendered to you, by them.

Sounds straightforward? It is, but unfortunately, Medicare is not! The MBS (Medicare Benefits Schedule) Handbook is over 1300 pages long. This is the rulebook that governs what we can and can’t do through Medicare.

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Medicare has a lot of rules, but there are 2 big ones that you need to be aware of:

  1. For a medicare rebate to apply the patient (not just a relative or parent) must be present
  2. To legally bulk bill a patient, the Medicare rebate must be the only charge levied (with a few exceptions).

What bulk billing isn’t

Bulk billing is, unfortunately, not free. A common misconception. Bulk billing means no out of pocket costs, but it isn’t free. You are still paying for the consultation, just not directly. You are paying through your taxes via the Medicare levy. The more consultations are bulk billed., the higher the Medicare bill is, and that is passed on to you, the public.

Furthermore, bulk billing does not pay for everything. You can only be bulk billed for things in the Medicare Benefits Schedule (MBS). With your doctor, this will typically cover consultations, some investigations (such as an ECG or spirometry), and care plans.

What can be bulk billed?

Anything which is done face to face, in line with the Medicare benefits schedule. The MBS handbook is available to either buy or free online, and the website shows the descriptors which explain what the item numbers relate to.

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An example showing an item descriptor for a biopsy of a skin lesion

What can’t be bulk billed?

Medicare does not cover extras such as dressings or vaccines. It also does not cover cosmetic medicine or anything related to work. An example is if your workplace tells you to get a medical certificate for absence from work, this is not a medicare rebatable consultation and should not be bulk billed. Doctors can and have been fined and incarcerated for fraudulently bulk billing.

If you require a wound dressing, for example, you cannot be charged this as well as be bulk billed. That is illegal and it is Medicare fraud. A notable exception, however, is vaccines. You can be charged a private vaccination and be bulk billed for the consultation. This is allowed.

You cannot be bulk billed for a consultation that does not take place. This means that if the patient is not present for the consultation then you cannot be bulk billed. If you are, this is illegal. The same applies if you are a relative or parent worried about your children. If they are not present, regardless of the reasons, you cannot be bulk billed.

The same applies to most telephone calls or internet consultations. Other than very specific scenarios, these should not and cannot legally be bulk billed. If they are then your doctor may be breaking the law., and if your doctor is happily breaking the law, you should ask yourself if you really want them looking after you.

I can’t be bulk billed, what do I do?

You either pay for the service, or the doctor or clinic provides it for free. There are many things that clinics will provide for free, such as basic dressings and equipment, sutures etc.

if you can't be bulk billed you will have to pay
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Why don’t you offer universal bulk billing?

I would love to be able to offer bulk billing for everything for every patient. However, due to progressive real-terms medicare cuts, it is just not possible.

Quite honestly Medicare simply does not care about you receiving good quality, holistic care. Despite the evidence showing that this is the best possible approach to patient care, Medicare continues to prioritise shorter and shorter appointments with their rebates.

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Medicare rebates drop over the course of your consultation. Source.

Furthermore, as stated already, Medicare does not pay for things outside of the MBS. The problem is the Medicare Schedule can be extremely limiting, for example, it will not pay for any telehealth consultations with a GP unless extremely limited circumstances apply. They also will not pay for dressings or vaccines.

Costs

The vast majority of the funding General Practice gets is directly from consultations with patients. This is the doctor’s income, of which a large portion goes to the practice to pay for running costs. Costs include business rates, insurance, utility bills, equipment, supplies, and of course staffing costs.

Costs are always rising, and unfortunately, Medicare does not care about covering this rise in expenditure.

To provide high-quality care costs money. A single dressing, for example, can cost upwards of $20 for a single dressing, and Medicare does not pay for that. The clinic or doctor is paying that themselves if they give it free of charge.

Real scenario

Let’s use a common real-life example. A patient with a chronic wound requires daily dressings. The wound is complex and requires specialised dressings. The practice nurse is also used to do wound care, including the dressings. This will take approximately 15 minutes of the nurse’s time. A dressing pack is used. The examination couch needs to be cleaned after the patient, which uses cleaning materials and time, say 5 minutes. Whilst this is happening, the doctor will review the patient and most likely item 23 will be used as it is a complex wound, of which the medicare rebate will be around $37. The clinic will earn approximately $10-15 from this, the doctor around $20.

ExpensesIncome
Nurse time = $20$15
Dressings = $20
Dressing pack and other miscellaneous = $2
Total Expenses to the clinic = $42Total Income = $15

The total loss to the clinic = $27

running at a loss is not in anybody's interest
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If the clinic runs at a loss eventually they will have to close

Now if this is a one-off, the clinic may just bear this cost for the benefit of the patient. However, if this is a daily occurrence, which it often can be, you can see why bulk billing this patient is simply not affordable. What will the clinic do? Will they bear the cost and lose $27 per patient per day? Or will they simply tell that patient to go away and not come back, resulting in very poor care?

Consultations

GP income is typically the lowest of all medical practitioners. You may not care too much about that, but GPs need to earn money as well. If the doctor is not earning enough money, they simply will do a different job and we will be left without GPs.

With Medicare rebates reducing in real terms year on year, GP income is dropping even further. To counter this, most doctors who offer bulk billing do so on a ‘one problem per appointment’ basis. This is not a proper, holistic approach to healthcare. Dealing with all your issues in one appointment is possible, but it takes time. Medicare does not care about this. They continue to prioritise short consultations and penalise long consultations. Quite simply it’s not just feasible with current Medicare rebates.

Some doctors have chosen to move to even quicker and easier consultations. Some have even gone as far as ‘cherry-picking’ the easy consultations and refuse to see patients with more ‘difficult’ issues such as mental health or women’s health. This is abhorrent and punishes those most vulnerable in our society, yet this is what some doctors do to be able to function on bulk billing.

There are some doctors out there who are bulk billing and do a fantastic job. They provide high-quality care to their patients and are delivering excellent outcomes. However, in my opinion, these are rare.

I simply do not believe that you can offer a high standard of care to all patients whilst universally bulk billing.

What is mixed billing?

Mixed billing refers to the doctor private billing some patients and bulk billing others. This allows the doctor to provide a good standard of care to all their patients, whilst providing enough income to cover running costs and provide an income.

Essentially the private paying patients are subsidising the bulk billing patients. Personally I mixed bill.

Why should I pay a gap fee?

That depends on what you want and what your doctor is offering. Some will offer a concierge service, with excellent levels of access, but they will likely charge a lot of money for it. Others will charge less and yet still deliver a very high standard of care.

Some private billing doctors are bad and unfortunately still operate on ‘6-minute medicine’, but usually when you are privately paying it allows the doctor to spend more time with you. To not have to rush you out after 5 minutes because they need to see more patients per hour in order to get enough money to run the clinic. It allows the doctor to use proper materials and good equipment, that unfortunately, cost money to buy and maintain.

Some clinics are unfortunately guilty of ‘conveyer belt medicine’. They are in and out so quickly it’s almost a production line. This is not good care. Private billing allows the doctor to take the time you need.

Typically in a mixed or fully private billing practice, the wait times will be shorter too. When the doctor is charging a gap fee they can spend longer with each patient. They may be running on 15-minute appointments like me, or perhaps even longer. They are also less likely to overbook the clinic, which usually results in much less overrun.

Affordability

Undoubtedly some patients cannot afford to pay for a private paying doctor. As GPs we are often acutely aware of our patients’ finances, more so than even the bank manager. It’s amazing how open and trusting patients will be with us. We know that some people cannot pay for private billing. We may choose to bulk bill those in need. Private billing actually allows us to do this.

If we take the example given above, if the clinic is profitable, and the doctor is earning well, they are free to take the loss for that patient that really needs it.

Some people baulk at the idea of paying for their GP. In my experience though that is usually because they are receiving poor care or poor service, which they would never pay for. Many private billing doctors go the extra mile and really make that service worth paying for. This can actually make it much more affordable than you may think.

Previously I had a patient that was being bulk-billed by their doctor. There were no out of pocket costs for his appointments. However, his appointments were still costing him hundreds of dollars. Why? Because he was having to miss an entire day’s worth of work to attend each one. What was he coming in for? Lots of stuff, but it was 1 problem per appointment. He was also being brought back only to be told his results were normal and that was it. 30 seconds. He was having to take an entire day off work for 30 seconds.

Later on, he came to see me. I privately charged him, which he happily paid. Why? Well, I offered him so much more. I gave him results on the phone. Dealt with multiple issues at a time. He paid more, but the cost to him was so much less than his bulk billing doctor. He quickly realised the value of private billing.

Real life example

Should I pay privately or go bulk billing?

Ultimately it boils down to your priorities and your doctor. Some bulk billing doctors are fantastic and can make it work, delivering high levels of care and good service, but they are rare. What’s clear though is even for those who can make it work, the writing is on the wall. Medicare rebates are constantly dropping in real terms and the time is coming where bulk billing will not be viable.

Ask yourself, when that happens, would you be willing to pay for the service you are getting?

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