Medicare and Plastic Surgery

Medicare and Plastic Surgery

Medicare is the right of all Australians to be provided with medical health care on medical need.

Some procedures in plastic surgery will be required on a medical needs basis and these can include body contouring surgery after significant weight loss and reconstruction of facial deformity, such as post-traumatic rhinoplasty.

When patients approach a plastic surgeon regarding a procedure, the surgeon will decide if this procedure is medically necessary or whether it is elective.

If the procedure is medically needed, then it is likely that it will attract a Medicare item number.

The Medicare item number is the coding system used by Medicare to describe particular medically necessary procedures. This number is then used by health funds to determine whether hospital and operating theatre costs will be covered by the health fund, as well as determining rebates for anaesthetic and surgical services.

If a procedure does not attract or fulfill the criteria of the Medicare item number, then the procedure is deemed to be one hundred percent elective or cosmetic which means all costs related to that procedure, be it hospital costs, operating theatre costs, surgeon and anaesthetic costs would need to be paid by the patient.

The decision as to whether a Medicare item number is necessary for a particular patient needs to be assessed at the time of consultation.

The consultation will allow the surgeon to determine the medical need and whether a Medicare item number is necessary.

If a Medicare item number is necessary, it can only be used if the patient has been referred to the practitioner or referred to the specialist by a medical practitioner.

This is why it is important for patients who are seeking treatment of potentially medically related conditions, such as post weight loss surgery or post-trauma correction, to have a referral from a general practitioner. This referral chain ensures that the Medicare system is appropriately used and that all the criteria are satisfied to ensure that the procedure is a medical need and is not an elective procedure.

Advice to Patients

Dr Hunt advises his patients that a medical referral from a GP will mean they will have a rebate from Medicare for a portion of the initial consultation fee. Once this referral has been put in place from a general practitioner, any subsequent medical treatments that do attract a Medicare item number would be deemed to be medical in nature.

This is why you will find that many practitioners will request patients obtain a referral prior to seeking treatment so that, in the event that ongoing surgical treatment is implemented on medical grounds, it is done so in a valid and appropriate manner with the appropriate foundation in place at the first instance, being a referral from a general practitioner to the surgeon.

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