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Best tips to reduce gap fees

OSHCstudents – Out-of-pocket expenses or gap fees for hospital treatment can really hurt, especially when you’re not expecting them. And while talking about money can be uncomfortable, it’s helpful to know there are ways you can decrease your risk of being hit with a gap-fee unexpectedly after medical treatment.

First, let’s take a look at what an out of pocket cost, or gap fee, is.

What’s an ‘out of pocket cost’ or ‘gap fee’?

‘Gaps’ or ‘out-of-pocket costs’ are the difference between what you’re charged, and what Medicare and your insurer (if you have one), will pay for your treatment. Another way to think of it is ‘the amount you pay’.

So, how can you avoid these gap fees, or at least be aware of them before your treatment so you can make informed choices for your care? We’ve outlined some tips below.

Informed Financial Consent (or IFC) with all your doctors

If you’re going to hospital, there will usually be more than one doctor involved in your treatment.

It’s important to ask your specialists, and all doctors involved in your hospital treatment, to outline the costs involved in your treatment, preferably in writing, before your procedure. It’s worth checking what each part of the costs is for, so you know exactly what you’re paying for.

While this isn’t always possible (for example, in an emergency), this is one of the best ways to make sure you know what you’re going to be charged.

Find out more about Informed Financial Consent, and the responsibilities your doctors and hospital have.

More than doctors’ fees

Remember that medical expenses are made up of more than just your doctors’ fees, they can also include hospital costs, the costs associated with tests and scans and even in some cases, home care after your treatment.

Here’s a guide to the basic costs that can be involved:

  • Medical costs: The fees charged by a surgeon, physician, anesthetist, or other medical specialist when they are treating you in hospital.
  • Hospital costs: Charges related to staying in the actual hospital such as the use of the bed, food and operating theatre, plus nursing and allied health services.
  • Pharmacy costs: The cost of prescribed medication provided to you, or purchased by you, for treatment of your condition. This includes pharmaceuticals listed on the Australian Government’s Pharmaceutical Benefits Scheme Schedule (PBS), and, in some cases, non-PBS ‘High Cost Drugs’.
  • Prostheses costs: The cost of things that are surgically implanted like artificial hips or knees or cardiac devices such as pacemakers, and stay implanted when you leave hospital.On top of confirming your costs with your doctors, it’s worth asking your hospital to confirm, in writing, what you can expect to pay for these other costs.

    Find out more about who pays for your hospital treatments

Medical Gap Scheme

Many health insurance funds have arrangements with specialists, which aim to help reduce the costs you pay in doctors’ fees when you go to hospital.

They might call this a ‘Medical Gap Scheme’, ‘Gap Cover’, ‘MediGap’, or something else.

Where a specialist chooses to use your insurer’s medical gap scheme for your treatment, they agree only to charge up to a certain fee. Your insurer then pays a much higher amount than what they normally would, so that you pay less.

A specialist may be part of a medical gap scheme, but not use it for your treatment. They can choose whether they want to use it each time.

Look at all your treatment options

Looking at all the treatment options for your condition could save you a trip to hospital, and maybe some money along the way too.

Sometimes you need to go to hospital, and other times you might not. For example, if you injure your shoulder, you might be able to manage the injury through physio or other treatments, rather than surgery. It’s worth checking with your doctor what all the options are for treating your condition, so that you can make an informed decision.

Public options

Once you’ve got some information on what you’re likely out of pocket expenses are likely to be, it’s good to remember that you can choose to go through the public system if you’d prefer.

While you may wait longer in the public system for planned procedures, many of these expenses will be covered under Medicare, and could help you avoid any gap fees.

On the other hand, you will not get the normal benefits of going private, like choosing your doctor, reduced waiting time for elective or planned procedures, and the ability to request a private room. It depends on what’s most important to you.

To help you make the choice between public and private, it’s good to understand the differences of each choice.

OSHCstudents (source: Bupa)

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