Medicare Referral Validity: A summary for practice staff

Do you know how long an indefinite referral lasts? Do you know the rules about if and when you can bill another initial consult item on a new referral? Practice staff are encouraged to learn the Medicare rules regarding Referrals. Responsibility for the accuracy of medical billing ultimately lies with the servicing provider, however a savvy receptionist can be instrumental in identifying potential billing errors before they even occur, simply by knowing the rules and gently advising the practice manager or the doctor if you believe there is reason to bill differently.

Here are the basic essentials:

  • GP referrals last 12 months (unless clearly marked as “indefinite”) from the date of the first appointment using the new referral. An Indefinite referral can often fail via electronic transmission if it is greater than five years old.
  • Specialist referrals last 3 months from the date of the first appointment using the new referral.
  • A new consultation item can only be billed with a new referral if the patient has not been seen for the same condition within the last nine months.
  • Referrals must be signed and dated BEFORE the appointment date, and cannot be back-dated.
  • No referral = no medicare payment

This information is just a general summary. To get everything you need to know for your practice, read these articles:

  1. Medicare Referrals and Requests
  2. Referrals, initial consultations and Medicare compliance by Michael Wade, Avant Special Counsel – Medicare

Be the billing watchdog for your practice –  reduce lost income for the practice, and improve your Medicare compliance.

Here is another great article on Referrals –