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What will my gap be?

My fee structure

Different levels of reimbursement

What are my fees?

 

 

Latest News (7/4/17)

 

HBF and GMHBA introduce known-gap policies

 

HBF and GMHBA have recently introduced known-gap policies in line with the AHSA Access Gapcover scheme.  This is a significant improvement from previously, and will this will reduce the out-of-pocket expenses for my patients insured by these companies by up to $250 – from a maximum “gap” of $550 down to a maximum “gap” of $300.

 

HBF and GMHBA have now joined BUPA and HCF who have also in the last 5 years introduced known-gap policies.  The major insurer now without a known-gap policy is NIB (which insures about 10% of the market), and so patients insured with NIB will still be subjected to higher out-of-pocket expenses than most other insured patients.  There are some more minor insurers (Latrobe, Cessnock) and some policies within other insurers (ACA, Australian Unity, Budget Direct) that do not have a known-gap policy, and there are some other minor insurers (Mildura, Budget Direct, Frank) that do have a known-gap policy but which is so minimal that it will not protect patients from higher “gaps”.

 

 

 

My fee structure:

I charge fees at three different rates depending on the circumstance.

Health insurance companies reimburse you at different rates depending on who you are insured with and sometimes which policy you have within that insurer.

Your “gap” will depend on how many “units” your anaesthetic is worth; which level of fee I charge; and how much reimbursement you receive from your health insurer.

 

Different levels of reimbursement

All health insurers offer slightly different levels of reimbursement for your doctors’ fees.  In general, insurers fall into 2 groups, depending on their level and structure of reimbursement.  In addition, there are 2 other groups – people who are uninsured (or their insurance policy does not cover this admission), and people whose insurance covers the full cost of doctors’ fees (Workcover, Motor Accident Insurance Board – MAIB, or Department of Veterain’s Affairs – DVA).  People who are insured but are not covered by Medicare (overseas residents) are different again, and their “gaps” will generally be similar to if they were insured by a “no-gap only” insurer.

 

Group “Known-Gap”

These insurance companies have “known-gap” policies as well as “no-gap” policies, and reimburse over and above the MBS by between 65% and 84% of the MBS (to $32.70-36.40 per “unit”, equivalent to approx. 41% of the AMA schedule).

These insurers include:

  • Medibank Private
  • AHM
  • St Luke’s Health
  • BUPA (including MBF, Mutual Community, and HBA)
  • ACA Health Benefits Fund (unless “basic hospital”)
  • Australian Unity Health Limited (some policies only)
  • CBHS Health Fund Limited
  • CUA Health Limited
  • Defence Health
  • Doctor’s Health Fund
  • Emergency Services Health
  • GMHBA
  • GU Health (Grand United)
  • HBF
  • HCF
  • Health Care Insurance Limited (HCI)
  • health.com.au

 

  • Health Partners
  • Health Insurance Fund of Australia Limited
  • Navy Health
  • Nurses and Midwives Health
  • onemedifund (National Health Benefits Australia)
  • Peoplecare Health Insurance
  • Phoenix Health Fund
  • Police Health
  • Queensland Country Health Fund Limited
  • Reserve Bank Health Society Ltd
  • rt (Railway and Transport) Health Fund
  • Teachers Health Fund
  • Teachers Union Health (TUH)
  • Transport Health
  • Westfund

 

 

Group “No-Gap”

These insurers do not have a “known-gap” policy, or otherwise their “known-gap” policy reimburses a very small amount only above the MBS hence does little to protect patients from larger “gaps”.  Most of them have what they call a “no-gap” policy, but for the patient not to have a “gap” these “no-gap” policies require the anaesthetist to discount their fees by at least 61%, and up to 80% from the AMA schedule.  Otherwise these insurers only reimburse $4.95 per “unit” above the Medicare rebate, to bring the total reimbursement up to the MBS ($19.80 per “unit”, or under 25% of the AMA schedule).  I do not discount my fees by this much for elective surgery, and so unfortunately my patients insured with one of the below insurers will only be reimbursed the MBS (or in some cases only slightly more), and will be out-of-pocket by a greater amount.

These insurers include:

  • NIB Health Funds
  • ACA (“Basic Hospital” policy)
  • Australian Unity (some policies)
  • Budget Direct
  • CDH Benefits Fund
  • Frank Health Insurance
  • Latrobe Health
  • Mildura Health

 

 The only time I discount my fees by more than half to the “no-gap” schedule is when the operation is a genuine emergency and there has not been an opportunity to “shop around” if desired.  Examples include people being transferred from the LGH emergency department for surgery, or people on the ward returning to theatre for an unanticipated second operation.

 

What are my fees?

Standard fee.

My standard fee is $82 per “anaesthesia basic unit”, which is close to the AMA schedule.

I charge my standard fee in the following circumstances:

-  Treatment is covered by Workcover, Motor Accident Insurance Board, or another third-party insurer (these boards reimburse doctors according to the AMA schedule, and so there will not be a “gap”).

-  The treatment is primarily for cosmetic purposes and is not covered by your private health insurer.  These services may also incur GST (ie, $82 per “unit” plus $8.20 GST per “unit”).  I apply a 10% discount if payment is made in full at my rooms before the date of the surgery.

-  Payment has not been timely (within 4 weeks of the invoice being sent), and so my “discount” has been retracted.

In these cases, the “gap” will depend on how many “units” the anaesthetic is worth.  Some examples are illustrated in the tables below.

 

Discounted fee.

In most circumstances I discount my standard fee by one third (to $55 per “unit”), on the condition that payment is made within 4 weeks of the invoice being sent.  If payment is late, the discount will cease to apply.

I discount my fees further for age pensioners or people of working age with Centrelink healthcare cards – by 45% from the AMA schedule (to $45 per “unit”), again conditional upon timely payment.

In addition, I pre-define a “maximum gap”.  If the anaesthetic service is worth so many “units” that my fee minus your rebates from Medicare and your health insurer is greater than the “maximum gap”, then I will reduce the “unit value” of my fees further such that my fee is equivalent to your rebates plus the “maximum gap”.

The size of the “maximum gap” will depend on if you have private cover or not, and if your insurance company has a “known-gap” policy or if they only have a “no-gap” policy.

 

Maximum gaps

Admission covered by Workcover, MAIB, or DVAno “gap”

Insured with a policy from “Group ‘Known-Gap’”$300

Insured with a policy from “Group ‘No-Gap’”$550

Uninsured, or admission covered by Medicare but not by insurer:  $650

 

Age Pensioners or working age with Centrelink Healthcare Card

 Admission covered by Workcover, MAIB, or DVA: no “gap”

Insured with a policy from “Group ‘Known-Gap’”: $150

Insured with a policy from “Group ‘No-Gap’”: $350

Uninsured, or admission covered by Medicare but not by insurer:  $550

 

Below are some tables of anaesthetic fees for certain operations, indicating the different components of reimbursement and the out-of-pocket “gap”.

(Note 1:  This is a guide only.  Gaps in “Group ‘Known-Gap” will differ by a few dollars per “unit” depending on the insurance company, and the number of “units” may be greater or less for your particular operation than in the example below, also affecting the size of the “gap”.

Note 2:  In the third party insurer group, the “total fee” and “health insurer rebate” are accurate for MAIB and for Workcover, but they are different for DVA.  DVA’s schedule is not displayed separately here.  The “Gaps” are accurate – patients in this group do not incur out-of-pocket expenses for my anaesthetic services.)

 

Table 1:  knee arthroscopy – 45 minutes

Example 1:  Knee ArthroscopyTable 2:  tonsillectomy – 1 hour

Example 2:  Tonsillectomy and Adenoidectomy

Table 3:  laparoscopic cholecystectomy, 1 hour 30 minutes

Example 3:  Laparoscopic Cholecystectomy

Table 4:  total knee replacement, 2 hours 30 minutes

Example 4:  Total Knee Replacement

Table 5:  cosmetic surgery – breast augmentation, 2 hours

Example 5 Breast Augmentation