Billing Information

Information about our billing system

What is Medicare?

In 1985, the Commonwealth Government introduced Medicare as a ‘safety net’ for medical care in Australia. At this time the Medicare Benefits Schedule was formulated.

In short, this is a document which covers all medical procedures for which there is a Medicare rebate. It lists the item number associated with a particular service, both consultations and operations, and assigns the “schedule fee” and a benefit which is refunded to patients under the Medicare scheme.

This schedule fee 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 1990-1991).

Although there is a yearly increase in the Medicare Schedule Fee, these Government determined fees have not increased at the same rate as the Consumer Price Index (CPI) since 1985. Therefore, patients now find themselves in a situation of having to pay a ‘gap’ to cover medical services provided to them by Surgeons and other Medical Providers.

Unfortunately, to provide exceptional care to patients, Doctors are faced with increases in the cost of running their practices, continuing professional development, and increasing Medical Indemnity insurance costs. Therefore, if a Doctor continued to charge only Government-determined fees, effectively this would mean a reduction in their salary on a yearly basis.

The Australian Medical Association (AMA) issues its own schedule of fees. These fees are simply the Commonwealth Government schedule of fees from 1985, increased to keep pace with inflation. Your doctor may charge according to this schedule of fees.

How is my refund calculated?

Medicare will refund part of the cost of your medical procedure as long as the procedure is covered by their Schedule of Fees. Most common procedures and consultations are covered. Some treatments such as cosmetic surgery are not covered by Medicare. The Medicare eligibility of a procedure will need to be confirmed prior to the treatment being undertaken. Your Doctor can advise you of this.

Medicare will rebate 75% of the schedule fee for an in-patient (in hospital) service or treatment, and 85% of the schedule fee for out-patient (out of hospital) treatment. Your doctor will generally charge more than the Medicare rebate, and therefore you will be responsible for any charges over and above this rebate.

When does my Private Health Insurance pay a refund?

Your private health insurance will only pay for services performed as an in-patient. Previously, government legislation dictated that your private health fund could only refund up to the schedule fee. Hence they pay the 25% which Medicare does not refund.

However, in recent times legislation changes have allowed Health Funds to enter into agreements with Surgeons, allowing your health fund to refund higher amounts if your Surgeon participates. These agreements differ between health funds and it is at the discretion of your Surgeon as to his or her level of participation.

Some health funds allow for a co-payment arrangement between the Patient and the Surgeon. In these cases, there will still be an out of pocket fee, however this will be much lower than if your Surgeon participates in a “Gap Cover” arrangement. Again, it is at the Surgeon’s discretion as to the level of participation in these arrangements.

How much will my surgery cost me?

You should discuss payment with your Surgeon prior to your procedure. A full quotation will be provided to you. However, please remember that this is a quotation only, and your Surgeon may have to do more or in some cases less than initially expected which could cause a difference in costs to those originally quoted.

You will be provided with an Informed Financial Consent which will outline your costs, based on the proposed surgery, and will also outline your financial commitment to your Surgeon for your surgery.

It is better to ensure you know all estimated expenses prior to the surgery. If you are unsure of any costs, please contact your Surgeon’s office to discuss this.

You may also receive an account from the Hospital, the Anaesthetist, Radiology, Pharmacy, or Physiotherapy. There may also be costs for rehabilitation devices such as knee braces or crutches. These accounts generally arrive after your surgery, and are separate and independent of your Surgeon’s cost. Your Surgeon’s Secretary will be able to advise you in relation to gaining quotes for such items.

Will I be able to get a quote before my consultation?

You will be able to find out the cost of an initial consultation with your Surgeon at the time of making your appointment. You will need to clarify this cost and any Medicare rebate payable following payment of the account. It is advisable to do this at the time of making your appointment.

Once you have seen your Surgeon and you make the decision to have surgery, you can contact your Surgeon’s office to arrange a quote. Unfortunately, until you have a consultation, we are unable to provide a quote for surgery as there are many variables which may affect the costs.

At no time will reception staff be able to determine what operation you will require nor will they be able to decide whether gap cover will apply. This is a decision that your Surgeon will make.