Insurance and Medicare - general advice

Frequently asked questions

The insurance company won’t allow claims for a group or class.
What does the APA say about preferred provider schemes?
Do I need my own provider number?
Can someone else, including a locum use my Medicare number?
I need a Private Health Insurance number.
Can I request diagnostic imaging?

The insurance company won’t allow claims for a group or class.

Some insurance companies have different policies related to groups and classes and patients may shop around for insurance companies that meet their needs.

HCF, for example, has clarified that exercise classes for fitness, core strength or wellness are not claimable as either physiotherapy or through HCF’s Health Management Program.

If you run groups or classes, you should ensure that the way you describe your groups or classes matches the following descriptors:

Group: Groups typically have 6 participants or fewer who are being treated with individually designed interventions for the treatment of a specific health condition. Group physiotherapy requires pre-intervention assessment, individually designed interventions for each group participant, re-assessment and clinical record keeping e.g. noting improvements and prognosis.

Class: Classes may have any number of participants but participants perform the same exercises.

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What does the APA say about preferred provider schemes?

The APA remains concerned that health funds actively divert their members to network providers, regardless of existing therapeutic relationships.

The APA believes the term ‘preferred’ might make a patient think a practice is of a particular standard than those practices that are not preferred. This is not the case. By being a preferred provider, a physiotherapist simply elects to join the scheme and bring their fees in line with what the health funds mandate. We know this is a significant disadvantage to physiotherapists and that keeping fees close to market rates is essential to maintain the financial viability of a physiotherapy business.

We have raised this matter with the ACCC , which has not determined this is a matter for further investigation. We will continue to advocate for change when appropriate

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Do I need my own provider number?

Yes. Each physiotherapist must have their own provider number. You cannot use someone else’s provider number. The provider number is practitioner and location specific, so if you move to another practice location or move interstate, you must apply to Medicare to get a new provider number. Physiotherapists can contact Medicare on 13 20 11.

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Can someone else, including a locum use my Medicare number?

A locum (locum tenens) cannot use another person’s Medicare number.

If the locum will be in a practice for less than two weeks and will not be returning there, they should contact the Department of Human Services (provider liaison - 132 150) to discuss their options. Frequently this means the locum will use one of the locum's other provider numbers.

Where a locum will be in a practice for more than two weeks or in a practice for less than two weeks but on a regular basis, the locum should apply for a provider number for the relevant location.

Please refer to the Medicare Benefits Schedule – Note G2.3

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I need a Private Health Insurance number.

You should contact the health insurance provider. Click here for a list of contacts.

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Can I request diagnostic imaging?

Physiotherapists may request diagnostic imaging services for which the patient receives a Medicare rebate.

With the exception of the items listed in table 1, Medicare benefits are generally not payable for diagnostic imaging services that are classified as R-type (requested) services on request from a physiotherapist.

NR-type (not requested) diagnostic imaging items can be used by physiotherapists, but the clinical relevance of the service is determined by the diagnostic imaging service provider, so it is a good idea to establish a relationship with the imaging providers in your area.

APA advises our members not to refer for MRI scans if the referring physiotherapist does not have the necessary skills to interpret the MRI data. If a physiotherapist does not have a specific clinical skill, such as interpreting MRI data, refer the patient to a GP and request the radiologist report.

Further, Medicare likely will not cover the costs if an MRI is ordered by a physiotherapist and so the patient would be out-of-pocket.

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