What is the MBS?
The Medicare Benefits Schedule (MBS) is a list of medical services that Medicare will pay a rebate for. The Medicare Schedule Fee is the proposed cost that the Government has deemed appropriate for the service.
The Australian Medical Association (AMA) this document which is a guide for patients to understand how the healthcare system funds medical care. It is also worth reading this publication from the Consumers Health Forum (CHF).
The main points are:
- You can claim 100% of the Schedule Fee for visiting a GP.
- You can claim 85% of the Schedule Fee for MBS listed non-GP out of hospital care.
- You can claim 75% of the Schedule Fee for MBS listed services in a private hospital.
- The service provider may charge more than the Schedule Fee – this results in a ‘Gap Fee’ or ‘Out of Pocket Cost’ that you will need to pay.
- Admission to Public Hospitals is free of charge for Medicare Card holders but private hospital stays will typically include some out of pocket costs.
Why do I have Out of Pocket Costs?
You may be required to pay an ‘Out of Pocket’ fee in two main circumstances;
- Your doctor or specialist has charged more than the Medicare Schedule Fee when providing out of hospital care.
- Doctors can set their own fees, this is to cover their income and expenses including other staff, rent and equipment.
- The AMA states that “since Medicare began 40 years ago, Government indexation of Medicare Schedule Fees have not kept pace with real increases in practice costs.This is why today patients will find there is a difference between the amounts of the fee their doctor charges and their Medicare rebate.”
- When you are being treated as a private patient in a hospital
- Your health insurance may have an agreement with the hospital that they will cover all of the costs, however this is not always the case. It is important to be aware of which hospitals your health insurance fund has agreements with.
- Your doctor may choose not to participate in your health fund’s gap cover arrangement. Before agreeing to a procedure with any doctor in the private system it is important to ask if you will need to pay anything more than what your health insurance will cover. Gap cover and out of pocket costs explained from CHOICE.
Informed Financial Consent see from the Commonwealth Ombudsman for further details.
What Is The Cost Of My Procedure? see Medibank for further details and the cost comparison sites at the end of the article.
AMA Informed Financial Consent – a collaboration between doctors and patients.
Comparing prices
Many specialists don’t make their fees publically available but they are required to advise patients of the costs involved prior to any procedure or surgery and should do so in writing. Additional costs often include items such as:
- Fees payable to other treating doctors involved in your care such as the anaesthetist, pathologist and surgical assistants
- Note – your surgeon will usually have direct relationships with a few anaesthetists and your ability to choose your own anaesthetist is limited to those few. See How much will my anaesthesia cost? provided by the CHOICE organisation.
- Prosthetic devices (eg. hip replacement)
- Hospital accommodation
- Medications (especially if you are required to take medication home with you)
- Radiology and pathology
Mind the Gap is a website that allows you to search for a limited range of specialists by location and consultation price. If you are visiting your GP for a referral to a specialist it may be worth looking at prices, deciding which specialist you would like to see and requesting a referral to them.
Seek Medi is a similar service.
My Dr. Bill provides a range of costs for a limited range of procedures in Private Hospitals.
Health Share allows you to search for specialists that may participate in your health insurance gap scheme. It shows the gap that other patients with health insurance have been charged for seeing that specialist.
Medical Costs Finder is an Australian Government initiative that helps patients find out more about the cost of specialist medical services.
If a specialist hasn’t published their fees you can always call and ask the staff.
Negotiating Cost
It may feel uncomfortable asking the specialist to consider reducing their fee but they will often be willing to discuss their fees for patients suffering extreme hardship.
- This article from CHOICE provides helpful advice, including:
- Be upfront if the fees are too expensive for you, explain your financial situation.
- Ask if they can charge under the no-gap or known-gap from your health insurance.
- Ask your health fund for a list of specialists that have a no-gap arrangement.
- You could also ask your surgeon whether any of the anaesthetists they work with are willing to consider reducing their fee on hardship grounds.
Unfortunately, many patients either find it too uncomfortable, or are too unwell to negotiate fees, this is an area of health care that needs greater transparency.
Avoiding unexpected costs
See page 5 of the following link for helpful guidance on the questions to ask:
http://www.ombudsman.gov.au/__data/assets/pdf_file/0016/35611/Doctors-Bill-DL-Fyler-Web.pdf