When a practice charges a fee above the Medicare benefit rate, a Bulk Bill claim is not the correct claim type. This is one of the most common Medicare billing mistakes and it is important to understand the distinction.
What is Bulk Billing?
A Medicare Bulk Bill Claim means the practice agrees to accept the Medicare benefit as full and final payment for the service. No additional fees can be charged to or collected from the patient. When you submit a Bulk Bill claim, Medicare pays the rebate directly to the practice, and the patient pays nothing out of pocket.
If a practice collects any additional amount from the patient on top of the Medicare benefit, that appointment cannot be billed as a Bulk Bill claim. This is a breach of Medicare billing rules — for more information, see the Department of Health's guidance on bulk billing and additional charges.
When to Use a Patient Claim Instead
If your practice charges a fee above the Medicare benefit rate, you must submit a Medicare Patient Claim instead.
With a patient claim:
The patient pays the full fee to the practice at the time of the appointment (including any gap amount)
The claim is submitted to Medicare on the patient's behalf
Medicare pays the rebate directly to the patient, deposited into the bank account they have registered with Medicare
The practice retains the full fee collected from the patient
The gap amount (the difference between the practice fee and the Medicare benefit) is not recoverable from Medicare and is paid solely by the patient.
In Summary
| Bulk Bill Claim | Patient Claim |
Who pays the practice? | Medicare | The patient (upfront) |
Can a gap be charged? | No | Yes |
Who receives the rebate? | The practice | The patient |
For instructions on submitting each claim type in PracSuite, see: