Finding out the cost of your hospital treatment

28 May, 2018

It’s not always easy to work out how much you’ll need to pay for medical treatment as a private patient in a hospital in Australia.

Healthcare in Australia can be complex and can be paid for by a combination of the following:

Commonwealth Government (through Medicare)
State and Territory governments
private health insurance
out-of-pocket costs that you may need to pay

Before you have treatment, it’s a good idea to ask how much it will cost.

What is informed financial consent?

Informed financial consent is way for you to know how much your treatment is likely to cost.

Before you receive treatment, you have a right to ask your doctor, your private health fund, and your hospital how much it will cost. You also have the right to know if they’ll be any out-of-pocket costs that you’ll need to pay. Your out-pocket-costs are commonly known as the gap payment.

What do you need to ask?

The Australian Medical Association recommends that you ask your treating doctor or specialist the following questions before you go to hospital:

what are your fees?
are there fees for other doctors like anaesthetists or surgeons?
will I have to pay any out-of-pocket costs?
can I have an estimate of all your fees in writing?
if the cost changes, when will you let me know?
what if I need a prosthesis or implant?
do you participate in my health insurer’s gap cover scheme and will you treat me under it?

You should ask your hospital:

do you have an agreement with my private health fund?
will I need to pay any extra costs during my treatment or gap payments?

If you have private health insurance, you should ask your private health fund:

does my policy cover this procedure or treatment?
will I need to pay an excess, co-payment or any other charges?
am I on a waiting period and do I need to provide you with medical certificates?

It’s best to ask for all of this is writing. The Australian Medical Association has an Informed Financial Consent Form template that gives you an idea of what to expect in a written estimate of fees.

How do doctors set their fees?

In Australia, doctors can decide how much to charge for their services. This means that doctor’s fees will vary.

You can use the Medical Costs Finder at the Department of Health to:

get an idea of how much people have paid in out-of-pocket costs for a procedure
compare the costs your specialists have quoted for a hospital procedure with the average cost in your area

How much will Medicare cover?

The Australian Government sets a fee for most medical services. This is known as Medicare Benefits Schedule (MBS) fee. This is the amount the Australian Government thinks the service should cost, but doctors are free to charge more than this amount.

Medicare will cover:

75% of the MBS fee for in-hospital treatment as a private patient
85% of the MBS fee for out-of-hospital services

If Medicare doesn’t recognise a procedure or service, it means they won’t cover it. It also means your private health insurer probably won’t cover it either.

If you’re not sure if Medicare will cover a service or how much they’ll pay, you can call the Medicare general enquiries line on 132 011. It’s open 24 hours a day, 7 days a week.

What about emergency admissions?

If you’re admitted to an emergency department of a hospital, it might not be possible for your doctor to get your informed financial consent before they treat you. When this happens, your doctor should provide you or someone representing you with the estimate as soon as possible.