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If you require day surgery or a medical procedure where you’ll be admitted and discharged from hospital on the same day, chances are you’ve asked about private hospital day surgery fees.

The cost of day surgery in private hospitals can differ widely, depending on the treatment you’re receiving, where you’re being treated and who’s treating you.

Examples of common day surgeries in Australia

  • Cataract surgery
  • Wisdom teeth removal
  • Arthroscopy (examination and/or treatment of damage to the interior of a joint)
  • Cystoscopy (examination and/or treatment of the bladder and urethra)
  • Dilation and curettage (light scraping of the womb)
  • Ear grommets (plastic ventilation tubes that treat ear infections)

Is day surgery covered by my health insurance policy?

Day surgeries require formal admission into the hospital or facility for treatment to be covered by your health insurance policy. The treatment you require must be an inclusion on your chosen policy and you may or may not be required to pay the excess or co-payment when you’re admitted.

Based on your type of policy and choice of insurer (including your insurer’s gap cover agreement, which we discuss further on) may also be covered towards the cost of:

  • pathology and radiology tests
  • dressings used in surgery
  • operating theatre fees
  • meals
  • medications costing more than the approved value of the Pharmaceutical Benefits Scheme (PBS) – a scheme where the Australian Government subsidises certain medications
  • allied health services, including physiotherapy, hydrotherapy and occupational therapy.

The true cost of private hospital day surgery fees

Despite paying for private health insurance, the total cost of your day surgery may not be covered by your policy.

With regard to any private admission, all procedures carry a government assigned Medicare item number, each item number is assigned a government agreed cost or value under the Medicare Benefits Schedule (MBS) for the surgeons and anesthetist costs. When it comes to claiming, Medicare covers 75% of the MBS cost of procedures, while your private health insurance will cover the remaining 25% of the MBS cost. If your chosen surgeon or anesthetist chooses to charge over the MBS this is known as the ‘gap’

Separately to this your private health insurance policy may also cover the other costs of your hospital admission, theatre fees, medication, dressings and additional testing. It’s common to also be out of pocket for the excess amount on your chosen policy.

Example: The MBS fee for a grommet myringotomy (a surgery where a small cut is made in the eardrum to relieve pressure or to insert grommets) as $242.60. Medicare will pay $181.95 (75%) of the total $242.60 meaning your insurance would cover the remaining $60.65 (25%).

However, there are cases where health professionals will charge more than the MBS fee. As such, you may need to pay a gap or out-of-pocket expense to cover these private hospital day surgery fees.

Overall, always ask for an informed financial consent form before treatment, so you’re aware of all costs and if you can claim insurance for your day surgery.

Day surgery and gap cover agreements

Health funds have agreements with different hospitals and facilities on agreed costs, and doctors agreements known as gap cover agreements. If your treating doctors have this agreement with your health fund, and they choose to use this for your admission, they will only charge up to an agreed amount (commonly $500) or won’t charge you more than you’re your policy will pay, eliminating or reducing your out-of-pocket costs.

Check if your health fund has an agreement with each health professional involved in your day surgery, such as your surgeons, assistant surgeons or anesthetists. If there’s no agreement, you may need to pay the individual cost each health professional charges for their service above the MBS amount i.e. the ‘gap’.

The Australian Government’s private health website has a tool to search for hospitals that have an agreement with health insurers.[i] Failing to use a partner hospital could leave you with significant out-of-pocket expenses – even if you take out private health insurance.

Are certain day surgeries excluded from private hospital policies?

In Australia, there are four-tiered health insurance categories, each which has minimum requirements that need to be covered. The difference between a basic hospital product and a gold hospital product are the services that it includes or excludes, so it is important to know your level of coverage. According to the Commonwealth Ombudsman, Australia’s most commonly excluded services and restricted services* include:

  • eye surgeries, such as cataract and eye lens procedures
  • services related to birth and pregnancy
  • infertility services
  • reconstructive surgery, such as skin grafts or reconstructive surgery following cancer
  • joint surgeries.[ii]

Other things your health insurance may not cover include:

  • crutches, medication and other items vital for your recovery at home
  • additional support provided to you by doctors or specialists after your surgery
  • respite care
  • blood products such as donated blood
  • TV, phone calls and other services available in private rooms.

There are also surgeries that the MBS doesn’t cover, such as cosmetic surgery that’s not medically necessary. Your private health may cover part of these costs or may not cover them at all.

What’s more, your policy may have other exclusions and restrictions on what you can claim. As such, do your research, check your policy’s information document/brochure and talk to your insurer, so you’re aware of what’s covered before undergoing surgery.

Our health insurance comparison service can help you find a policy that may cover treatment costs unique to your circumstances. More expensive health insurance tiers, such as Gold or Silver, will cover a wider range of day surgeries than Bronze or Basic. However, the procedure you require may still be available on a cheaper tier.

*Restricted services are services your insurer covers if you’re a private patient in a public hospital.

If you seek treatment as a private patient in a private hospital for a restricted service, your health fund won’t cover your theatre fees – though they may pay a small amount towards your accommodation fee.

happy child patient in a hospital bed with a male medical professional

Are there health funds with no excess for day surgery?

Whether you need to pay excess for your private hospital day surgery depends on your fund and chosen policy. It’s not uncommon for funds to waive the excess for day surgeries, but these waivers vary between policies and funds.

Excess is a set amount you agree to pay when you’re admitted into hospital and make a claim on your hospital cover. You can choose your excess rate when you take out your policy but remember; the lower your excess, the higher your premiums are likely to be.

Slightly different to excess is a co-payment – where you agree to pay a set amount for each day you’re a private patient at either a private or public hospital usually capped at a yearly limit.

Are there waiting periods for day surgery under private health insurance?

If you haven’t already signed up for a policy, you’ll need to wait a certain length of time before you can claim any surgeries. Thankfully, you won’t need to wait longer than a year from treatment to claim.

The government has set the following guidelines that health insurers must follow:[iii]

ServiceWaiting period
Pre-existing health conditions12 months
Birth-related services and pregnancy12 months
Rehabilitation, palliative care and psychiatric careTwo months
All non-preexisting conditionsTwo months
Extras coverHealth insurers can set these waiting periods

How do inpatient and outpatient procedures differ?


While both inpatient and outpatient procedures can be performed on the same day, they are treated differently when it comes to private health insurance. These procedures may also incur different private hospital day surgery fees.

Outpatient surgery doesn’t require a formal admission into hospital and is therefore not usually covered by your health fund except in special circumstances. For example items such as removal of an infected toenail in the doctors surgery, meeting a specialist or undergoing a blood test without being admitted to hospital as a patient is not covered by your policy.

Outpatient treatment can include treatment in an emergency room, specialist doctor consultations before treatment and most assisted reproductive services or treatments.

Circumstances where outpatient treatment may be eligible for cover include:

  • Some psychiatric programs where your health fund has a specific agreement with the hospital for the service you are booked in for; or
  • the treatment you require is specified under your policy and your health fund has an agreement with the facility.

On the other hand, inpatient treatment means you’ve been admitted to hospital by a health professional and undergone a procedure. Depending on the procedure and your coverage you can be covered by your policy.

As always, read the product description carefully for information specific to your health fund and the individual policy.

Our health comparison service allows you to easily compare private health policies and the features they offer. In addition to day surgery procedures that may be covered, you’ll also be able to assess what each level of cover offers, other benefits, extras and more. The best part is it takes just minutes to use our service and it’s completely free to compare.

Sources

[i] PrivateHealth.gov.au – ‘Agreement hospitals’ Accessed October 2019

[ii] Commonwealth Ombudsman – ‘Policy Exclusions and Restrictions’ Accessed October 2019

[iii] Department of Health – ‘Private health insurance laws’ Accessed October 2019

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