HCi Factsheet - ambulance cover
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Understanding doctor bills
March 2024
Doctors deserve to be paid for their services – but how are those fees determined?
Who sets the fees to create doctor bills?
In Australia, doctors can set their own fees and charges.
So fees for any particular service can vary. Fees depend on the doctors expenses (such as premises rent, hiring staff and having relevant equipment) and their belief of what their time and expertise are worth.
You can ask a doctor about their fees before any consultation or treatment. Ideally, they will provide this as written information although it may be an estimate to allow for unexpected complications. Obviously, in an emergency or some other situations, a doctor will treat you without your financial consent. But they should provide that information as soon as possible.
But what about Medicare schedules?
Through Medicare, the Government helps cover your medical expenses.
The Medicare Benefits Schedule lists a fee for each service. Doctors can charge whatever they like, but Medicare will only pay a proportion of the scheduled fee:
- 75% for in-hospital treatment as a private patient
- 85% for out-of-hospital treatment
- 100% of in-hospital treatment as a public patient
For covered members, HCi will pay the remaining proportion of the scheduled fee for inpatient services – we are generally prevented by regulations from paying above the scheduled fee. The difference between the Medicare schedule and your doctor’s fee is called the gap.
Note that a hospital stay may include multiple medical specialists (eg radiologist, surgeon, assistant surgeons, anaesthetists, physiotherapists) who will each bill you.
If a service is not in the schedule, Medicare will not pay for that service. And HCi usually doesn’t cover such services either.
What is bulk billing?
Some doctors will charge Medicare for their out-patient services, meaning you do not have to pay anything. This is called bulk billing.
Doctors can use bulk billing for all services or in select circumstances. For example, many doctors will bulk bill for children but charge fees to adults.
What can I do with large medical bills?
If you receive medical bills that are bigger than expected, or just larger than you can immediately manage, stay calm!
If you are convinced you have been charged more than is correct, the Private Health Insurance Ombudsman recommends paying what you expected to pay or the scheduled fees. Then contact the doctor to discuss the issue.
Some, or all, of the following tips may help you…
- check what you originally agreed to – if that’s different to what the bill includes, you can ask the doctor (or the doctor’s administration staff) to explain why it changed.
- contact your doctor and ask about the various services listed – were they all done? did things take longer so fees went up?
- talk to your doctor about a payment plan – it’s better to pay some of the bill rather than just ignore it.
- discuss your situation with the doctor and see if a reduced fee is possible
- talk to HCi – we may see why the fees are higher or maybe realise you are covered for more than you expected
To access the Ombudsman services at no cost, contact them via:
www.ombudsman.gov.au and www.privatehealth.gov.au
phio.info@ombudsman.gov.au
GPO Box 442, Canberra ACT 2601
1300 362 072 between 9am and 5pm (AEDT) Monday to Friday.
Or call 131 450 to use the Translating and Interpreting Service (TIS).
Or call the National Relay Service on 133 677 for a TTY service.
How to keep medical costs down
You can still get quality medical care when you need it, but there are some ways to manage the fees and avoid nasty shocks when the doctor bill arrives.
- make sure your health insurance is current and suits your current needs. Remember that paying a little more in health insurance can mean a lot more cover and thus lower medical costs
- discuss alternatives with your doctor before any treatments – there may be more affordable options
- ask questions about fees before agreeing to the treatment. Think of questions like
- what are the scheduled fees for these services?
- does your doctor work with the HCi Access Gap program?
- are any other medical providers involved who will bill me? How do I get an estimate of their costs?
- how and when will the doctor bill me? Are payment plans offered?
HCi used its best endeavours to ensure this information was accurate at the time of publication. From time to time, circumstances relating to the subject matter may change which may impact the accuracy of the information. This information is also general in nature and does not take into account any specific health or financial situation. Before making any decisions in relation to this information, you should consider your own financial and health situation and seek professional advice. Health Care Insurance Ltd ABN 43 009 579 088. A Registered Private Health Insurer.
