Private Surgical Treatment –

Who Pays for What?

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Private Patients

Many people who have private surgery are surprised and dismayed when the bills come in, and after Medicare and their private health insurer have made their contribution there is still a gap to pay.  Medicare will pay 75% of the Schedule Fee and your private health insurer pays the other 25%.  Although private health insurance covers most (but not all) hospital costs it does not cover the difference between the Medicare rebate and the doctors’ fees.  Doctors involved in your treatment will probably include the Surgeon, an Assistant, an Anaesthetist, and pathology and radiology services.
 
Before you have private surgery it is important that you find out what your out-of-pocket costs are going to be. The doctor’s rooms can only provide you with an estimate because the actual treatment required may differ slightly from the proposed treatment.  Ask which costs can be claimed on Medicare and private health insurance and which cannot.  Then you wont be embarrassed when the bills arrive as you will have already budgeted for the gaps.

It is also important that, before you have private surgery, you are very sure your private health insurance fund will actually pay for it.  You must always check your eligibility, for example if you have a pre-existing ailment and have only just taken out private health insurance you may have to wait for 12 months before the insurer will pay for treatment.  If you have recently changed your level and type of insurance there may be restrictions that apply, so you also need to check with your insurer beforehand.  Similarly it is wise to confirm what excess payments you will have to make, for example the policy you have may be one where you pay the first $200 or $500 of hospital admissions in a given time period.  Don’t confuse ‘Extras’ cover with hospital cover.  ‘Extras’ insurance covers such things as physiotherapy, dental, and optical treatment etc but does not cover hospital treatment.  On the other hand, if you do not have ‘Extras’ cover you will probably have to pay for physiotherapy out of your own pocket.

Remember that many hospitals ask you to pay ‘up front’ before they admit you, so you need to check how much this is likely to be and be prepared to pay at the time of admission.   Some hospitals also expect you to make a contribution towards your daily room rate so you need to ask the hospital what this is likely to be.

WorkCover, Third Party and Veterans Affairs

If someone else is expected to pay for your surgery, such as WorkCover, a Third Party payer, or Veterans’ Affairs, you must have written prior approval for the surgery to proceed or else you will have to pay for it yourself.  Having a file number is not enough, as this simply proves that the claim is being processed but not that it has been approved.

Self Insured

Some people choose to be ‘self insured’, that is they have no private health insurance and are prepared to pay for private treatment, over and above the Medicare rebate, out of their own pocket.  The doctors’ fees are likely to be the least expensive, with hospital and ancillary fees amounting to much more.  Hospital fees include such things as daily bed fees, theatre fees, the cost of surgical aids and implants, other aids such as crutches and splints, and miscellaneous charges such as drugs, dressings, etc.

You don’t really want to be worrying about all of these things when you are recuperating from surgery, so……


Questions about fees need to be asked before rather than after private hospital treatment. 

  Make sure you ask the doctor’s staff for an outline of likely costs and an estimate of what they might be before you commit your self to undergoing private surgery.

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