How to avoid bill shock with out-of-pocket surgery expenses

Hospital visits are stressful at any time, but the lack of transparency around out-of-pocket hospital and medical expenses, what Medicare covers and what your health insurance provider covers, can be an even more painful and expensive maze to navigate.

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Choice recently found that having private health insurance can expose you to thousands of dollars of out-of-pocket costs, while public patients enjoy the same treatments for free.

According to Choice, private patients can be slugged with expenses such as consultations with your doctor while you’re in hospital, procedures you are not covered for, pathology costs such as blood tests and prostheses such as an artificial hip. Private patients don’t typically pay for these services.

Having private health insurance usually means you can jump waiting queues and have your operation sooner, and stay in a more comfortable hospital. It also means you can choose your own doctor.

However, it’s the ability to choose your own doctor that introduces the gap payment – which is the difference you pay, between what Medicare and your private health fund will pay towards your treatment and what your doctor charges.

Through the Medicare Benefits Scheme (MBS) the government has tried to standardise the cost of a range of treatments, medical procedures and tests, and Medicare will pay 75 per cent of the MBS fee for the treatment of private patients in hospital. Your insurer will pay the remaining 25 per cent.

The problem of large and unexpected gap payments arises because doctors aren’t bound by the MBS. They can effectively charge whatever they want for your surgery, meaning you pay more in out-of-pocket expenses.

Choice found that a quarter of those surveyed who had paid a gap, said they’d been out of pocket more by than $3,000.

While the costs for different surgeries can vary widely, Choice reviewed and compared costs for common surgeries like a gall bladder removal and colonoscopy.

On average, the total out-of-pocket costs for gall bladder removal surgery including hospital and doctors’ fees was about $7800. A quarter of patients were charged an out-of-pocket fee from the surgeon of about $850 on average, Choice’s research found.

For a colonoscopy, the total out-of-pocket costs including hospital and doctors’ fees was about $1900. Nine percent of patients were charged an out-of-pocket fee from the surgeon of about $270 on average.

Gaps in surgeon’s fees varied quite significantly across the states, and a detailed breakdown is available on Choice’s website.

“Gap costs, especially if they’re higher than expected or even a surprise, are a common frustration for consumers with the health insurance market. True reform is needed to clear up consumer confusion,” says Erin Turner from Choice.

Choice recommends a few tips and tricks on how to save on surgeons’ fees, including:

  • Ask you GP about any potential out-of-pocket costs with the surgeon they refer you to.
  • Ask the specialist (or surgeon) for a detailed breakdown of all of the costs associated with your procedure, and be insistent if they will not provide you with an estimate of costs.
  • Shop around – get a number of quotes from different specialists so you can for yourself where the costs differ.
  • As for names of specialists in both the private and public system to see the costs differences.
  • Discuss your surgery with your health insurance provider, and ask for a list of surgeons they have an agreement with.

In October, Health Minister Greg Hunt announced a reform package for private health insurance, which includes establishing an expert committee to consider out-of-pocket costs.

With all the confusion about the true cost of surgery, it would seem that the reforms can’t come fast enough.

Have you been stung by over-the-top or unexpected out-of-pocket surgery costs?