Private Surgical Treatment - Who Pays for What?
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.