Private Health Insurance
The system of private health insurance in Australia is rather complicated and changes regularly.
This information is provided to give some information and guidance, but there are often differences depending on the insurer, type of insurance and the type of service provided.
In the case of in room consultations, private health insurance does not pay the surgeon or patient any part of the cost. A fee is charged by the specialist, and depending on whether this is a first visit, new condition, or a follow-up visit, Medicare will reimburse the patient a portion of this fee. At this practice we are usually able to process this reimbursement by an electronic process so that it is transferred immediately from Medicare to your account.
For surgical procedures, the situation is more complicated. Essentially there are three systems. “Fixed rates”, “Known Gap”, or “No Gap”.
The surgeon charges a fee to the patient (the amount may be guided by suggestions from the Australian Medical Association – “AMA rate”). Medicare and the insurance company each reimburse the patient a portion of this fee. If this system is used, the insurance company contribution is very low compared to the other options, so the patient ends up a lot out of pocket
This is the same as the “No Gap” scheme (see below), but the fee offered to the surgeon is felt to be too low to reflect the difficulty of the case. The surgeon asks the patient to make a co-payment to make up the difference between what he thinks is reasonable, and what the insurance company is offering. The insurance company sets upper limits on what co-payment is allowed. If the surgeon really felt this was still inadequate, he would need to revert to the “Fixed Rate” system. Unfortunately for the patient, this would mean they end up paying even more than a “known gap” would have been for the same total fee to the surgeon. This practice uses known gap fees for most patients with appropriate private health insurance.
The insurance company offers to pay the surgeon directly somewhat more than the patient would have been reimbursed under the “fixed rate” scheme. The surgeon accepts this fee, and it and the money from Medicare (“the rebate”), are paid directly to the surgeon.
For some reason, this amount varies greatly between different insurance companies and if the surgeon is trying to keep the cost to the patient as low as possible, he/she has to just accept what they offer. At this practice, “No Gap” billing is often used for pensioners and health care cardholders.
Informed financial consent
You will receive an informed financial consent form regarding out of pocket expenses for the surgeon’s fee when you make your booking for surgery. The surgical fee includes initial follow up visits, however, later consultations beyond normal follow-up periods, usually attract a separate charge.
If you require further clarification of the above please discuss with Mr Callahan or the staff at reception. If you find that the fees charged are likely to cause severe economic hardship please speak directly to Mr Callahan.
Medicare is really a base level of medical insurance for all Australians run by the government. You can be treated at a public hospital at any time and not be charged directly for the service.
As stated above, for outpatient, in room consultations, Medicare are the ones who reimburse a part of the fee to the patient
If you do not have private health insurance, you can still have surgery in a private hospital. You will be charged a fee directly by the surgeon, his/her assistant, the hospital, and the anaesthetist and some of this will be reimbursed by Medicare. A quote for the surgeon’s fee can be provided to you, if pursuing this option.
If you are seen in the hospital as an emergency after an accident or having been referred by another doctor, there will be an “Emergency Call Back Fee”. This is typically between $300 and $500.
Similarly, if it is necessary for the surgeon to request the input of another specialist doctor to your care, they may charge a fee.
It is routine for the surgeon to use an assistant. Assistants’ fees are calculated at a rate of 20% of the surgeon’s fee. This will often be paid directly to the assistant by your insurance company, but not always
The anaesthetist will discuss their fees with you separately. The service provided by and fees charged by them is entirely separate to the surgical fee.
The hospital may charge admission fees and/or there may be an excess on your insurance policy payable prior to admission depending on your insurer and the particulars of your policy
There may be a charge for inpatient physiotherapy, radiology, or pathology services that are necessary during your admission.
Discharge medications and some medications given during admission may be payable separately
Some surgical procedures require the use of an x-ray machine in the operating theatre known as an image intensifier. The radiology department at the hospital will bill you directly for the use of this service
Any prostheses (plates, screws, implants etc) or other consumables used during surgery are usually covered under the cost of the admission as a whole. There are rare occasions where a specific implant is not covered. This would be discussed prior to surgery.
The cost of the “Patient Specific Cutting Guides” used for the “Prophecy” technique in ankle replacement surgery is not covered by insurance companies or Medicare.