The cost of appendicitis surgery

When you’re treated through the public healthcare system, Medicare covers the entire cost of an appendectomy for public patients in a public hospital. However, you won’t have the option to choose your own doctor or recover in a private room. If your surgery isn’t considered urgent, you may have to join a lengthy public waiting list.

If you choose to be treated as a private patient in a public hospital, or be transferred to a private hospital for your surgery, Medicare covers 75% of your doctors’ fees, as set out in the Medicare Benefits Schedule (MBS). If you have a suitable level of private hospital insurance, your insurer will then cover the remaining 25% of the MBS fee and some or all of your hospital costs (e.g. accommodation and theatre fees).

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) may need to pay what’s left. This out-of-pocket cost is known as a gap payment.

In the 2021-22 HCP Annual Report, 78.6% of privately treated patients who had an appendectomy with minor complexity owed a gap payment. Of the patients who did pay a gap, the average gap paid was $619.³

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.

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).

The main benefits of being treated in a private hospital with health insurance are being able to recover in a private room and choose your own 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, x-rays or blood tests).

Your health fund will pay some or all of the private hospital costs (not covered by Medicare) and 25% of the MBS fee for your surgeons and anaesthetists, with Medicare covering the other 75%.

While you may still have to pay the gap, it might not be as bad as you think when you consider the following:

• Some hospitals and doctors have agreements with health funds. So, if you’re treated in an agreement hospital for appendicitis and your doctors participate in your health fund’s gap cover scheme, 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 may not have any out-of-pocket costs. However, you will need to make sure every doctor involved in your treatment participates in your health fund’s gap cover scheme, or you may still have a gap.
• If you have a known-gap agreement, you’ll have a limited gap payment for the hospital or doctor. Typically, you’ll be made aware of the gap amount on a known-gap agreement before surgery. However, if your surgery is an emergency, you may not be able to be informed beforehand.

Remember, if you’re taken to the hospital in an ambulance, you’ll most likely be taken to the nearest available public hospital emergency room instead of a private hospital with a gap agreement. You may then have the option to be transferred to a private hospital of your choice.

If you attend a private emergency room, it’s important to understand that you’ll have to pay the private emergency department fees yourself. This is because emergency departments are outpatient facilities and aren’t covered by private health insurance.

Once you’re admitted to hospital as a private inpatient, you’ll be able to claim on your private hospital policy, provided you have the right level of cover, the admission is medically necessary, and you’ve served any relevant waiting periods.

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.

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’ll be required to serve a twelve-month waiting period before claiming on related services, such as surgery for appendicitis. Always check with your insurer and read the 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.

For private patients without hospital insurance, the average cost for an appendectomy with minor complexity was $6,887 in 2021-22.³ 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.

Ambulance transportation could come at a cost in most Australian states and territories (excluding Queensland and Tasmania). Private health insurance can help cover ambulance journeys, which can be expensive without cover.

Depending on your health fund and the hospital you’re recovering in, you may face an out-of-pocket co-payment for each day you remain in hospital to help cover accommodation and food costs. It’s also likely that you’ll have to pay an excess on admittance to hospital.