Financial disclosure, consent and "The Gap"​

Your appointment

 

We allocate time for a longer consultation for new patients. When you book your appointment, the practice manager will inform you of the costs of the appointment, some of which you will be able to claim from Medicare and/or your private cover. Payment can be made by cash, cheque, credit card or EFTPOS. Our Medicare online claiming system allows us to process your Medicare claim for you on the spot.


 

Those patients suffering from financial hardship can still be seen at Mackay Base Hospital (see "Why do you work at two hospitals?" on our "Home​" page)


 

All about "The Gap"

What is the gap?

The gap is the difference between what a doctor charges and the Medicare rebate and/or insurance payout.

Why is there a GAP? 

 

The Medicare Benefits Schedule is a list of operations which is compiled and updated by the Commonwealth Government. Each operation is allocated an item number and a fee. It is not a recommended fee – it "simply represents the amount that the government, having regard to budgetary and economic considerations, is willing to pay (Auditor General Report No 32 1990-91)." The Medicare rebate is the amount that you can claim back from Medicare, and is 75% of the Schedule fee for in-hospital expenses (such as operations) and 85% of the Schedule fee for out-of-hospital expenses (such as consultations). The Schedule was established in 1985. If back then a doctor charged the Schedule fee, the gap between the refund and the fee would have been 25% of the fee for in-hospital expenses and 15% of the fee for out-of-hospital expenses. In other words, if the Schedule fee for an operation was $1000, the Medicare rebate would be $750 and the gap would be $250.

 

Unfortunately, the Schedule has not increased in line with inflation. Thus if a doctor continued to charge the Schedule fee, they would be effectively be taking a bigger and bigger pay cut each year. This is why most doctors charge more than the Schedule fee, and why the gap between the fee and the Medicare rebate continues to increase. In other words, if the doctor increased their fee for the $1000 operation to keep up with inflation, they would now charge about $1700 for the operation, and the gap would now be $950. This includes the difference between the Schedule fee and the doctor's fee ($700), and the difference between the Schedule fee and the Medicare rebate ($250).

 

The AMA (Australian Medical Association) issues its own Schedule of fees, which is simply the Schedule fee from 1985, increased to keep pace with inflation (the CPI). Whilst this would seem to be fair, we charge less than the AMA fee, to try and reduce the cost to patients.

What are multiple item numbers?

 

There is often more than one part to an operation and this means there may be multiple item numbers. An example is an ankle fusion, where there are separate item numbers for putting the screws in, taking the bone graft and doing the fusion itself. If there is more than one item number, the Schedule fee decreases for each item number as follows: 100% for the first (most expensive) item number, 50% for the second (next most expensive) item number, and 25% for each subsequent item number. In other words, if there are three item numbers for an operation, and the Schedule fee for them individually is $1000, $800 and $400, the Schedule fee for the procedure would be $1500 ($1000 + $400 + $100).

What is bulk-billing?

This is where doctors accept the Medicare rebate directly from the Government as payment of their fee. This means that in 1985, they were accepting 75% of their fee (ie. discounting by 25%) for in-hospital services, and accepting 85% of their fee (ie. discounting by 15%) for out-of-hospital expenses. Because of inflation, the fee that bulk-billing doctors accept is decreasing in real terms each year. This can certainly mean that the quality of care that can be provided is affected. For these reasons, we do not bulk-bill.

What if I have private insurance?

 

Most health funds will make up the difference between the Medicare rebate and the Schedule fee for in-hospital expenses. In other words, if the Schedule fee for the operation is $1000, the Medicare rebate for the operation is $750 and the health fund rebate is $250. There will still be a gap, and this will be the difference between the Schedule fee and what the doctor charges.

What is GAP-COVER?

Until recently, health funds were not permitted to cover the cost of the gap. Now they can. Each fund has its own schedule (list of fees they pay for specific operations) and its own rules. If the doctor chooses, the bill can be sent directly to the health fund and the doctor is paid the amount the health fund has decided for that particular operation. Some funds allow the surgeon to charge more than the health fund gap cover rebate. You then pay the difference (called co-payment) - see the example at the end of this page. 

Why do some surgeons not participate in gap cover?

Everyone would agree that decreasing the cost of treatment is an advantage. At first glance, gap cover schemes seem a good idea. Some surgeons have a number of concerns. The main ones are:

  • ​The setting of fees by the health fund rather than the doctor does not take into account the complexity of the particular operation you require or the doctor's level of experience.

  • The publishing of lists of 'gapcover' doctors (which are often inaccurate) interferes with the decision you and your GP make about which is the best specialist for your situation.

  • If the fund becomes too involved with the treatment, some surgeons are worried that it may lead to the introduction of managed care into Australia as has happened in the United States.

What is our policy?

At present we routinely charge somewhere between Medicare and AMA rates. We participates in gap cover with all funds, except MBF and NIB, who have a no gap policy. At your first visit, you will be provided with a copy of this information and if a decision is made to proceed with surgery you will be given an estimate of your surgical fee, any likely rebate from Medicare and your health fund, and your out-of-pocket expenses ("The Gap"). You will need to pay the gap or co-payment before proceeding with surgery. If you are privately insured and there is no "gap" to pay the bill will be sent directly to your health fund after the surgery. If you are not privately insured or there is a "gap fee" or "co-payment" to make, the bill will be sent to you after the surgery and you will be responsible for submitting the bill for reimbursement.

Will gap cover  bed used for my operation?

The reception staff are unable to decide whether gap cover will apply. They are also unable to give you a quote for surgery over the phone. This information is only available once you have seen us and the decision has been made about whether surgery is the right option for you. Once this decision is made, the exact nature of the surgery is discussed and the appropriate Medicare/insurance codes are found and a quote can be generated for you. This quote is given to you prior to placing on the waiting list and prior to surgical consent to allow you time to consider your options - a "cooling off" period. This allows you time to come to terms with the physical and financial costs of surgery.

An Example - You see us and we decide to offer you an operation. The planned operation has a MBS fee of $1000. Our fee is $1600. If gap cover does not apply, you will receive a Medicare rebate of $750. If you are insured, your health fund will reimburse you another $250. The gap is $600, which you will need to pay. If gap cover does apply and your fund's set fee for the surgery is $1400, you will have a co-payment to make of $200. You need time to consider both the surgery and the financial issues so we arrange for a follow-up appointment at your convenience with an appopriate interval to allow you the time to think things over and come to your own conclusion about the surgery without undue pressure.

This website & its elements were designed by Chris Wainwright & are not to be reproduced without permission.

Full acknowledgements can be found here.