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Articles Insurance How to save on your out-of-pocket costs for surgery and medical fees
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How to save on your out-of-pocket expenses for surgery and medical fees

Following the ABC Four Corners Programs’ expose on out-of-pocket medical expenses and who’s really to blame, we’ve compiled practical advice for you on how to protect your hip pocket.

The eye-opening program revealed some telling truths for patients about the inconsistency in surgeon and specialist fees which make up the large part of out-of-pocket costs paid by private patients.


Why is there sometimes a gap?

Medicare sets a standard fee for all medical and hospital charges, called the Medicare Benefits Schedule (MBS) fee. The MBS fee is a predetermined fee the government considers appropriate for the procedure you’re having.

When admitted to a private hospital, Medicare will reimburse 75% of the scheduled MBS fee they have set for each procedure, and Private Health Insurance pays a minimum 25% back – and in most cases significantly more.

When specialist and other medical fees are set higher than the MBS fees, it creates a ‘gap’, hence most out-of-pocket costs paid by private patients are for surgeon and specialist fees charged above the MBS.

Four Corners Program Host Sarah Ferguson said, “the most common reaction is to blame the insurer, but our investigation shows much of the fault lies with specialists charging extortionist fees.”

Private Healthcare Australia’s Chief Executive Dr Rachel David, who contributed to the investigative report, said health funds have no legal influence over specialists’ fees and charges.

“Furthermore, many consumers do not realise health funds are prevented by law from insuring services that occur out-of-hospital, like visits to specialists, pathology tests and scans.”


What can you do to protect your hip pocket?

First and most importantly you have a right to know upfront how much you’ll be out of pocket for your surgeon’s fees before booking your surgery.

“The really important point to make is that the patient is not powerless. You need to be empowered to ask the right questions of your specialist, so you have a clear understanding of what you’re being charged, why and how you can influence that,” said Health Partners CEO Byron Gregory.

“The number one question you should be asking your surgeon, specialist or anaesthetist before treatment, is whether they participate in a no gap or known gap scheme and if they don’t or won’t – be prepared to go elsewhere,” Mr Gregory said.


Access Gap Scheme

An Access Gap Scheme (or no or known-gap) is an agreement Health Partners has with participating specialists and surgeons to limit your medical expenses.

“It ensures that when you’re treated in hospital, you will either have no gap to pay, or know your exact gap before treatment,” Mr Gregory said.

Specialists can decide on a patient-by-patient basis if they’d like to participate in Access Gap and remember if your specialist doesn’t use Access Gap, you pay the medical gap – the amount charged above the MBS fee.

Health Partners, like most health funds, has a list of doctors that participate in the Access Gap Scheme.

Dr John Batten, President Royal Australasian College of Surgeons told the program, “Some people out in the community feel someone who’s got very lush premises as their rooms, who charge high fees are clearly much better than other surgeons. There is no evidence that’s the case. I think that’s very important the public understands that.”

“This is about giving patients back some control over not only their health decisions but the decisions that hit their hip pocket by getting them to ask the right questions and be prepared to negotiate or go elsewhere,” Mr Gregory said.

Reduce or eliminate your gap payment

  • Talk to your GP. Your GP needs to be aware costs are a concern, so they can help you find a low-charging specialist;
  • Don’t be afraid to speak up – ask your specialist to provide the costs in writing and in person and get them to explain any items you don’t understand;
  • Ask if there will be any out-of-pocket costs (excess or co-payment) and whether they participate in the Gap Access Scheme;
  • Ask for the fees of any other doctors involved, such as an assistant surgeon or anaesthetist;
  • Don’t be afraid to negotiate;
  • If they are charging a booking or administration fee, ask what it is for – any such fee should be questioned as to the relevance of your actual medical care.
  • Remember: higher fees do not guarantee a better quality of care;
  • You have a right to a second opinion;
  • After surgery, if you have had complications or there are unexplained charges on the bill, do not pay it until there has been an explanation from your doctor;
  • And importantly, speak to your health fund. Most funds have websites and other tools available, which list specialists covered by their Gap Cover schemes, who charge either no gap or a known gap.

We encourage any members who have any questions about taking some control over their surgeon’s and specialists fees, to contact us on 1300 113 113.

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