Avoiding unexpected doctor’s costs

Treatments & procedures

Avoiding unexpected doctor’s costs

Understanding doctors' fees and charges is the key to avoiding bill shock.

Lisa Herron
August 2018

Having a medical procedure in hospital can be stressful. It’s normal to be focused on what the treatment involves and how it’ll go. Then there’s organising logistics at work and/or home. But it’s also important to be fully informed about the costs of your procedure before you get to hospital – to avoid a nasty shock when bills arrive.

Doctors’ fees and charges

In Australia, doctors are free to decide what to charge for their services (these are known as ‘medical costs’). The Government sets a fee for most medical services in the Medicare Benefits Schedule (MBS). When you have treatment in hospital, Medicare rebates 75% of the MBS fee, and your private hospital insurance pays the other 25% (provided you’re covered for the service).

However, many doctors choose to charge more than the MBS fee. This means after Medicare and your health fund contribute, there’s still a difference. This is often called the “gap” or “out-of-pocket” costs (we’ll explain how to avoid these gap costs below).

Finding out the cost

It’s important to know all the likely costs related to your procedure before you have treatment.

HCF’s Medical Director Dr Andrew Cottrill says it’s common to feel uncomfortable talking to your doctor about what they charge. “We appreciate that asking about fees and charges can be difficult, but it’s your right to be fully informed,” he says.

Being aware of all the costs, understanding and agreeing to them is known as informed financial consent.

Ask for a written quote with a breakdown of the costs (the more complex your procedure the more detailed this may be). Ask for the Medicare item number(s) too – this is the unique code Medicare assigns to each procedure (or part of a procedure) and items like prostheses.

When you have your item number(s), check with your health insurer whether your policy covers the procedure and if you’ll need to pay an excess, co-payment (contribution) or any gap costs.

Your doctor’s practice staff may be able to tell you what the Medicare rebate is for each part of your procedure, otherwise you can find out from Medicare. Also ask for details of any other doctors likely to be involved in your treatment (e.g. an anaesthetist or assistant surgeon) so you can get information about their fees and charges too. 

You’ll also need to find out about the hospital charges, as they’re billed separately from your doctors’ costs. Your hospital bill will cover things like your accommodation, operating theatre and other elements of your inpatient care.

How to avoid or reduce gap payments

For HCF members, the best way to ensure you have no, or lower, out-of-pocket medical costs is to choose a doctor who participates in our Medicover scheme. We have arrangements with specialists across Australia who provide over 95% of their services with no-gap or known-gap (capped at $500). Doctors who participate in our scheme bill us directly, so you don’t have to worry about managing the bills.

Ask your doctor if they’ll participate in our Medicover scheme. If they don’t, and they’re unwilling to, you can look for doctor who does.

Finding a participating specialist is easy using the Healthshare search tool. You can search by type of specialist and preferred hospital or location and get information about doctors’ biographies, locations, contact details and how often they participate in our Medicover scheme*.

HCF members can also avoid out-of-pocket costs on their hospital bills by choosing one of the many private hospitals we have an arrangement with (known as participating hospitals). If you’re treated at a participating hospital there won’t be extra costs for services covered under your policy (except for any applicable excess or co-payment).

It’s worth asking

HCF member, 30 year-old William Cameron, was shocked when he received higher-than-expected invoices in the mail before his nasal septum repair.

“I’ve had limited experience using my private hospital cover and was so confused by the fees and charges I actually considered not going through with the surgery.

“I called HCF and the consultant was really helpful. He explained that the hospital I was booked in for was one of HCF’s participating hospitals. My procedure was covered under my hospital insurance but I’d still have to pay the excess. He answered my questions, explained it all clearly, and encouraged me to call the surgeon’s rooms and ask whether he’d participate in HCF’s Medicover scheme. I figured it was worth a shot.”

Cameron’s surgeon agreed to participate which saved him over $2,000.

Received an unexpected bill?

If you’ve had a procedure and received a bill that you didn’t expect, or that was higher than you were quoted, Dr Cottrill advises not to just pay it. “Contact the doctor’s office and ask what the charges are for and why you weren’t informed,” he recommends. 

If you’re an HCF member and aren’t satisfied with their response contact us and we’ll either advocate on your behalf or recommend you contact the Australian Government’s Private Health Insurance Ombudsman.

HCF member checklist: questions to ask

Having an in-hospital procedure is a big deal – so do your research. Ask questions and get all the information you need to avoid unexpected bills and financial stress.

Ask your specialist or their practice staff:

  • Can I have a written quote with your fees for the procedure/s, with Medicare item numbers?
  • Do you (or will you) participate in HCF’s Medicover scheme?
  • If not, what will be the gap costs for me?
  • Are there any other charges, like outpatient consultations#, technology fees or management or booking fees?
  • Which hospitals can I have the procedure at to avoid out-of-pocket hospital costs?
  • What other doctors (e.g. anaesthetist or assistant surgeon) will be involved in my procedure and what are their contact details? (You’ll need to contact each one to find out their fees and charges.)

When you have all this information, contact HCF to find out if your policy covers the procedures, whether there’ll be any excess or co-payments, and if the hospital is a participating hospital.

We can help you work out what your out-of-pocket costs are likely to be and whether you can reduce them by choosing a specialist who participates in Medicover and/or a participating hospital.

Download our Gap Checklist.

Watch ABC’s Four Corners report on out-of-pocket medical expenses from May 2018.

* Doctors aren’t locked into medical gap arrangements and can choose to participate on a patient-by-patient basis. While we do our best to help HCF members access no-gap treatment, it can’t be guaranteed.

# Health funds, by legislation, can’t pay for outpatient consultations.


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