The cost of appendicitis surgery

Appendicitis is a potentially life-threatening condition, so medical professionals will usually treat it as an emergency. In this guide, we discuss on how appendicitis is treated, break down how much surgery may cost you and explore the benefits of hospital insurance, which we can also help you compare.

What is appendicitis?

The appendix is a thin pouch attached to your large intestine on the right side of your abdomen and can become blocked by food or faecal matter.¹ This blockage can lead to inflammation and the appendix can become infected, which can prove fatal if it ruptures.

Symptoms involve sharp abdominal pain, vomiting, nausea, diarrhoea and fever. While you can’t necessarily prevent this condition, it can be treated through either an open or laparoscopic appendectomy surgery (sometimes called an appendicectomy).

How does appendix removal work?

If you’re diagnosed with appendicitis, health professionals will assess whether your appendix has ruptured, which determines if your surgery can be laparoscopic (i.e. keyhole) or if you’ll need to have open surgery. They will also evaluate how urgently your surgery is required. Typically, your hospital recovery time may only be a few days.

The severity of your appendicitis will also determine whether your surgery will be laparoscopic or open appendectomy. An open appendectomy involves a larger incision made through the skin, underlying tissue and the abdominal wall to access the appendix, while laparoscopic surgery is less invasive, using smaller incisions.²

During laparoscopic surgery, a surgeon uses cameras and surgical tools inserted through small incisions to locate your appendix and remove it.

How much does appendicitis surgery cost without insurance?

For private patients without hospital insurance, the average cost for an appendectomy with minor complexity was $6,612 in 2020-21.³ This figure includes the surgery costs, doctors’ fees, theatre fees, anaesthesiologist fees and all other expenses accrued during your hospital stay and appendix removal operation.

However, this figure is just an average and doesn’t represent the actual cost you might pay. The price of an appendectomy will vary depending on where you’re treated, who’s treating you and whether there are any complications during the surgery.

Does Medicare or hospital insurance cover treatment for appendicitis?

Yes, through the public healthcare system, Medicare covers the entire cost of an appendectomy for public patients in a public hospital. When it comes to treatment as a private patient in either a public or private hospital, Medicare covers 75% of the hospital-associated fees, as set out in the Medicare Benefits Schedule (MBS).

If you have a suitable level of private hospital insurance, your insurer will cover the remaining 25% of the MBS fee.

However, keep in mind that private doctors and surgeons can set their fees above the listed MBS prices. This means that after Medicare and your insurer have covered their portions of the MBS fee, you (as a private patient) will need to pay this extra cost yourself if applicable. This out-of-pocket cost is known as a gap payment.

In the HCP Annual Report, 75.7% of privately insured patients who had an appendectomy owed a gap payment, which was an average of $604 in 2020-21.³

Depending on your policy and insurance company, you might also need to pay an excess for claiming on your hospital insurance or a hospital co-payment for every day you’re in hospital. In some cases the co-payment may be capped at a maximum cost per admission or per year.

Which type of hospital insurance policy would I need for an appendectomy?

Under the hospital insurance tiers (Basic, Bronze, Silver and Gold), you’ll typically need at least a Bronze policy to be able to claim treatment for appendicitis, which falls under the category hernia and appendix. However, some Basic Plus policies may also offer cover for appendix surgery (check with your insurer and in your policy documents).

What’s covered by your hospital insurance for appendicitis?

The main benefit of hospital insurance should you need surgery is your own private room and choice of doctor (if available). Plus, the right hospital policy could help cover some of the following costs associated with an appendectomy:

• Surgeon fees
• Anaesthetist fees
• Operating theatre costs
• Admitted in-patient consultations
• Hospital accommodation
• Any prescriptions or medicine used in hospital
• Dressings and bandages
• Assistant fees.
• In-hospital diagnostic tests (e.g. CT scans).

Your health fund will pay the portion of the private patient hospital costs that Medicare doesn’t cover (up to the listed MBS fee). However, take note of the following:

• Some hospitals and doctors have agreements with health funds. So, if you’re treated in an agreement hospital for appendicitis, you might not have any out-of-pocket costs for your appendectomy (a no-gap agreement) or you may have reduced costs (known-gap agreement).
• With a no-gap agreement, you don’t have any out-of-pocket costs for the surgeon or hospital. However, you may have other costs depending on whether other doctors were involved in your surgery who charge above the MBS-listed fee.
• If you have a known-gap agreement, you’ll have a limited gap payment for the hospital or doctor. However, as appendicitis is an emergency, you might not know what this gap is before treatment, unless you’ve checked with your health fund before you start experiencing symptoms.

Remember, if you’re taken to the hospital in an ambulance, you might be taken to the nearest available public hospital emergency room instead of a private hospital with a gap agreement. If you attend a private emergency room, then it’s important to understand that you will be required to pay the private emergency department fees yourself. This is because emergency departments are outpatient facilities. Once you are admitted to hospital as an inpatient, you will be able to claim on your private hospital policy, provided you have the right level of cover, the admission is medically necessary, and you have served any relevant waiting periods.

Can I use my private hospital insurance in a public hospital for appendicitis?

If you’re treated for appendicitis in a public hospital, the hospital may ask you if you wish to claim on your insurance. Before agreeing to claim on your cover, ensure you ask the hospital and your insurer about all out-of-pocket fees you might face.

Public hospitals may ask if you wish to use your hospital cover as it helps save Medicare 25% of the surgery’s costs under the MBS. The hospital then charges your health fund the 25% instead of Medicare.

Using private health insurance for emergency surgeries

How long do you need to wait before you can claim on appendix surgery?

You’ll need to serve a 2 month waiting period before you can claim treatment for appendicitis. However, if you’ve shown any signs or symptoms of appendicitis within the six months prior to starting your private health insurance policy, it will be deemed a pre-existing condition. This means that you will be required to serve a twelve month waiting period before claiming on services, such as surgery for appendicitis. Always check with your insurer and policy documents.

If you switch to a new health fund but maintain your current level of cover, you won’t need to re-serve any waiting periods you’ve already completed. When switching policies or health funds without having finished a waiting period, you’ll simply pick up where you left off. If you increase your level of cover, then you will need to serve any relevant waiting periods for the upgrade services.