Your Guide to Medicare Provider numbers

Australia’s healthcare system is among the best in the world. It’s primarily funded by Medicare, the national health insurance scheme. Whether it’s through a visit to the pharmacist, hospital admission for surgery or vaccination during childhood, it ensures that all citizens and permanent residents have access to subsidised healthcare services and appropriate treatment.

While efficient, the Australian healthcare system is quite complex, as it comprises a range of service providers and health professionals from various organisations. These include the national, state and territory governments, as well as the non-government sector. Together, these institutions work to provide the healthcare needs of Australians.

This guide outlines everything you need to know about Medicare Provider Numbers. Please note that the information provided mainly applies to Australian doctors. However, restrictions for OTDs and FGAMS are explained as well.

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One critical aspect of the healthcare system is Medicare, which is funded by the Australian Government through taxation revenue. With this universal health insurance scheme, private practitioners like GPs are paid rebates for medical services and procedures they provide to the community. A good example of this is the case of bulk billing practices that only need to bulk-bill Medicare for all patient visits. This means that patients don’t need to spend any actual money for the consultation or visit.

Also, Medicare ensures that free hospital services for patients in public hospitals and Pharmaceutical Benefits Scheme or PBS-subsidised prescription pharmaceuticals remain accessible to all Australians.

All payable Medicare benefits in the country for the professional services provided by medical practitioners are regulated by the Health Insurance Act 1973 (Cth) and Medicare Benefits Schedule. However, to be able to request Medicare services, you need to have a Medicare provider number. This provider number is a crucial identification number if you are to offer services covered by Medicare.

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What is a Medicare provider number and why do doctors need it?

So what is a provider number? Why would doctors need it when they are already licenced to practice medicine in the country?

The Medicare provider number for doctors is a unique number issued to eligible health professionals — meaning they are known and recognised for delivering Medicare services. Depending on the provider number type for doctors, you can claim, bill, refer or request Medicare services. Some types of Medicare Provider Numbers are for interns only, and others are to assist with operations.

To apply for a Medicare health provider number, you need to be registered with the Australian Health Practitioner Regulation Agency (Ahpra) or an approved body. And since health provider numbers are non-transferable, it’s best to secure your own and register immediately so you can begin offering Medicare services.

What is the Medicare provider number application process?

The Medicare provider number application process is quite simple. However, prior to applying, GPs and medical specialists need to ensure they meet the eligibility requirements outlined in Section 19AA of the Health Insurance Act 1973 (the Act).

To become eligible for a Medicare provider number, you have to either be:

  • Recognised vocationally as a specialist, consultant physician or specialist general practitioner
  • Registered on the Vocational Register (AHPRA Specialist Registration)
  • Registered in an approved placement under Section 3GA of the Act
  • First registered before 1 November 1996 (some exclusions apply)
  • A temporary resident doctor with an exemption under Section 19AB of the Act, working according to that exemption
Process of applying for a provider number

When you’re ready to apply for your Medicare provider number, you may visit the appropriate Services Australia page.

You will be asked to use a form during your application for your initial Medicare provider number.

  • To find the appropriate form, select or click on the ‘medical practitioner’ link (or whichever applies to you).
  • Download the application form for a Medicare provider number. You can fill out the downloaded form on your computer or print it and then complete the form by hand.
  • Send your application and supporting documentation to Medicare Australia. This should be done long before your proposed commencement date.

According to the Services Australia page, the peak period for Medicare provider number applications is from December to April. It usually takes the government a few weeks to process applications and issue a Medicare provider number.

How to update the address for a Medicare provider number

For Medicare provider number address changes, or to keep banking information or contact details updated, you can use the Health Professionals Online Services (HPOS) to access your account.

Once you are logged in to your account, you can change your details or post updates as needed.

Is there a limit on how many Medicare provider numbers you can have?

If you want to apply for another Medicare provider number location, you’ll be happy to know that there is no limit to the number of Medicare provider numbers you can get.

To apply for another Medicare provider number for additional approved locations, you may do so through HPOS by using your Provider Digital Access or PRODA account. You can apply for as many approved locations via PRODA as well.

Restrictions for OTDs and FGAMS

Section 19AB of the Health Insurance Act 1973 (the Act) restricts overseas trained doctors (OTDs) or foreign graduates of an accredited medical school (FGAMSs) from being able to access Medicare benefits. This ‘moratorium’ generally applies for a period of 10 years from the date of the OTD’s or FGAMS’s initial Australian medical registration.

Medical practitioners who are restricted from getting a Medicare provider number for 10 years are those who:

  • Are considered overseas trained doctors or obtained their primary medical qualification in an accredited medical school located outside of Australia or New Zealand
  • Enrolled in a medical degree in Australia or New Zealand but held the status of a temporary resident (FGAMS), or those who were not a permanent resident or citizen of Australia or New Zealand at the time of their enrolment

These restrictions don’t apply if you work in a salaried position that doesn’t involve Medicare benefits, such as a public hospital.

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19AB Exemptions

Whether you’re an OTD or an FGAMS, you can qualify or apply for an exemption that will enable you to access Medicare benefits long before the 10-year moratorium.

To get an indefinite exemption from the restrictions, your best option would be to work in areas in dire need of medical services for at least 10 years:

  • Distribution Priority Area (DPA) for general practitioners. The DPA classification identifies places in Australia with a shortage of medical practitioners.
  • District of Workforce Shortage (DWS) for non-GP specialists. The DWS category refers to areas where people have very limited access to medical specialists, such as anaesthesiologists, cardiologists, general surgeons, oncologists and so on.

Previously, what is known today as a DPA was categorised as a DWS. Through the Distribution Working Group (DWG) established by the Australian Government, the then DWS methodology was subjected to review. This led to the implementation of changes in the terminology to reflect the needs of an area accurately.

Rather than using the conventional GP-to-population ratio, the revised DPA system considers the GP services currently available in an area or community, and the demographic characteristics and socio-economic status of patients living in GP catchment areas.

The new classification system came into effect on 1 July 2019.

How Alecto Can Help

If your practice or clinic doesn’t seem to be doing well financially, even with a high number of patients, it could mean there are concerns regarding Medicare compliance.

At Alecto, one of our areas of expertise is evaluating and analysing billing-related processes and services. We can make recommendations to optimise Medicare billings and improve the efficiency of your overall billing structure.

We also offer placements for FRACGP and similarly qualified doctors searching for ways to serve the community whilst receiving above-average GP earnings. We also have vacancies for locum GP jobs and work opportunities in group practices, family practices and corporate medical centres across Australia.

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At Alecto Australia, we are committed to finding GP jobs that suit your individual preferences and needs. Because we specialise in sourcing the best GP jobs for the best GPs, we have access to the largest number of permanent GP jobs in Australia.

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