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Optometric billing and Medicare for new graduate optometrists

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Luke Arundel
National Professional Services Manager

Key points

  • Optometrists can choose to participate in Medicare, which provides benefits for eligible patients for clinically relevant eye health and vision examinations performed by participating optometrists.
  • Optometrists need to have a location specific provider number for each and every location in which they practice. This is a Medicare identifier for you as a health practitioner.
  • New graduate optometrists should seek an initial provider number from Medicare as soon as their graduate registration with the Optometry Board of Australia is confirmed and they have an initial location confirmed to commence practice.
  • Not all eye examinations are eligible for Medicare benefits.
  • Optometry Australia has developed position statements that outline its position on optometric remuneration and bulk-billing and are useful contextual information for graduate optometrists to assist them in understanding optometry remuneration.

Medicare

All Australian residents and certain categories of visitors to Australia can claim Medicare benefits for services with participating optometrists. The Health Insurance Act 1973 contains legislation covering the major elements of the Medicare program. The Australian Government regulates the Medicare program through the Department of Health and Ageing.

Provider Numbers

To enable claims for Medicare benefits to be processed correctly for each and every optometrist, you need a provider number to identify the location from which you practise. Provider numbers are issued only to individual optometrists and are location specific. This means that if you intend to practise at more than once location, you will need to have multiple provider numbers. You cannot use another optometrist’s provider number. New graduate optometrists who do not have a provider number already should use the application form for an initial provider number (see below).

When completing this form, you will need to attach a copy of your registration certificate. This means you cannot submit this application until after you have received confirmation of graduate registration from the Optometry Board of Australia. This usually happens in June or December, depending on when your course finishes. You should attach this written confirmation (usually in email form) to the application form or you can download a registration certificate from the AHPRA website. This form should be faxed to Medicare and the fax number is found on the form.

Practising in more than one location

If you know you will be practising in more than one location when you start practising, you can seek multiple provider numbers when you submit you application for an initial provider number. You should attach the address details of the practice addresses at which you will be practising to the application form when you fax it to Medicare.

Payment for benefits

You can give authority for benefits that would usually be made payable to you to be transferred to another optometrist, or practice owner, or your employer. This is known as a pay group link and if you are an employee optometrist, you generally will need to complete a pay group link form when submitting your application for a provider number at a particular location. If you do not submit a pay group link form, benefits will automatically be made payable to you as the provider.

Need another provider number at a later date 

If you move jobs or need another provider number at a later date, you should use a different form to apply for this new provider number. Again, you can apply for multiple provider numbers using the one form if you attach the address details of multiple practices. If you are ceasing practice, you should close that provider number with Medicare six weeks after you cease working.

Locum Optometrist

A locum optometrist is one who temporarily fulfils the duties of another. An optometrist who is to provide eye examinations at a practice location as a locum for more than two weeks or will return to the practice on a regular basis for short periods must apply for a provider number for that location. If you are to provide eye examinations at another practice for less than two weeks, then you have two options:

  1. use a locum provider number (which usually is associated with your home address) or
  2. obtain an additional provider number for that location as you would when practising for a period longer than two weeks.

You might also need to consider payment for benefits associated with the Medicare eye examinations your provide and direct Medicare payments to a third party by arranging a pay group link to the practice contracting you as a locum.

Eligible Medicare examinations

  • a service has been performed and a clinical record of the service has been made
  • a significant consultation or examination procedure has been carried out
  • the service has been performed at the location listed with the provider number
  • the service has involved the personal attendance of both the patient and the optometrist and
  • is generally accepted in the optometry profession as being necessary for the appropriate treatment of the patient.

Ineligible Medicare examinations

  • attendances for delivery, dispensing, adjustment or repairs of vision aids
  • attendances filling of prescriptions written by other practitioners
  • cosmetic surgery
  • refractive surgery
  • tests for fitness to undertake sporting, leisure or vocational activities
  • compulsory examinations or tests to obtain a commercial licence
  • entrance to schools or other educational facilities
  • compulsory examinations for admissions to aged-care facilities
  • vision screening
  • where the expenses for the service are paid or payable to a recognised (public) hospital
  • where the service is provided by teaching institutions to patients of supervised students

More questions

Medicare and Optometry Australia have produced a number of useful guides that are relevant for graduate optometrists. If you have any specific questions, you can always contact Optometry Australia as we would love to help answer them.

  • MBS Online
    contains the Medicare Benefits Schedule (MBS) and all the explanatory notes to assist optometrists in claiming appropriately.

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