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Women Unnecessarily Forking Out Millions in Gap Fees

4 min read
15 Sep 2014

Australians forked out $158 million in medical gap fees in the first quarter of 2014[1], despite having private health insurance. A leading comparison service says this figure suggests that Australians are not aware that gap fees can largely be avoided or at least reduced by using doctors that have a gap cover agreement with their health fund. The need to avoid gap fees is especially important for women, who typically require a wide variety of health services during their lifetime.

Patients face a ‘gap’ fee when healthcare providers charge more than the Medicare Benefits Schedule (MBS) fee. For in-hospital care, Medicare covers 75 per cent of the MBS fee, while your health fund will typically pay the additional 25% (as long as you’re eligible for that particular benefit).

Abigail Koch, spokesperson at insurance comparison service, says as women tend to have a wide range of healthcare needs, they need to do their homework to avoid gap fees. To make sure they get the most out of their policy, they should also look at matching their specific healthcare requirements to their particular life stage.

“The first step is to seek healthcare providers with gap cover agreements from the list provided by your health fund. Take the time to get detailed costs from your doctor before any procedure, to make sure they’re on par with the Medicare Benefits Schedule fee. Additional medical practitioners such as anaesthetists also need to be listed on this agreement,” said Abigail.

With many unaware of the potential costs that they may face, outlines ballpark fees attached to basic female in-hospital and outpatient services.

Pap smear

  • Upfront costs at healthcare provider’s discretion.
  • Many GPs, clinics and health centres bulk bill for this service; however in some cases you may be asked to pay the fee upfront and claim back your rebate from Medicare at a later date. Doctors who choose not to bulk bill will likely charge an additional fee for this service.

IVF or fertility treatments

  • Initial fertility specialist consultation and any pre-treatment tests: approx. $200 each.
  • You may receive $71.40 back from Medicare following an initial consultation, however if you have already reached your Medicare Safety Net Threshold, this rebate may be higher. Some of the day surgery fees for IVF treatment should be covered by your private health insurance, so as long as you’re eligible for that benefit. If you don’t have private health insurance, you can expect to pay up to $2,000 for private hospital care and an anaesthetist.

Pregnancy and birth (in patient)

  • Obstetrician consultations and ultrasounds: approx. $300 each.
  • Natural birth (private doctor’s fee): approx. $1300-7500.
  • Specialist consultations, obstetrician’s check-ups and ultrasounds are not covered by private health insurance and can only be claimed, in part, through Medicare.  Most medical expenses during pregnancy will not be covered by private health insurance until you arrive in the hospital to have your baby.
  • It’s a good idea to talk to your gynaecologist about the sort of things that could cause complications during pregnancy and birth, to see if your health fund covers these eventualities.

Mental health

  • Initial and subsequent psychology consultation: approx. $235 per hour.
  • Private health fund hospital cover typically includes some psychiatric services (in-patient) however out-patient psychology services are included in some private health insurance extras policies.

Menopause and hormonal conditions

  • The most common treatment is Hormone Replacement Therapy. While HRT isn’t typically covered by private health insurance or Medicare, at least part of the doctor’s consultation fee can be claimed on Medicare. Health funds may contribute towards pharmaceuticals that aren’t listed on the Pharmaceuticals Benefits Schedule and cost more than $36.90.

Joint replacement

  • Hip replacement: approx. $36,000.
  • Hip replacements are typically classed as a comprehensive service, but they may appear on basic health insurance policies in you choose to be treated as a private patient in a public hospital. However, your options may be limited. If you think you’ll require such a service in the near future, firstly check that this is listed in your policy and remember that there may be a 12-month waiting period.

[1] Australian Government Quarterly Gap Payment and Medical Benefits Statistics March 2014

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