Out of Pocket Costs – What are the realist fees patients will pay?

Out of Pocket Costs – What are the realist fees patients will pay?

In a recent article “Australians being hit for huge out of pocket surgery costs”, surgeons (particularly orthopaedic surgeons), were questioned about the huge out of pocket costa for surgery.  It is important to break this down and to understand the cost that can be associated with private healthcare for patients.

Firstly, yes it is true that some surgeons charge more than others, and some patients will end up more out of pocket than others.  Patients need to understand that if they don’t like what a surgeon is charging they can go see someone else.  Patients don’t need to stay with the specialist recommended or advised by a GP.  Additionally, cost is no guarantee of quality.  I advise patients to do their research and to be well informed.

So lets break down the costs for a hip replacements.  As per the article $30,000 might sound terrible!  But this is not the amount given directly to a surgeon and would more likely represents the total cost of hospital stay, including the prosthesis (which will be the single highest cost), the surgeons fee, the assistant, the anaesthetist, theatre fees from the hospital, bed-stay fees, pharmacy, and physio. Looking at all of that, $30,000 is actually pretty good value.

The surgeons fee is only a small percentage of the “$30,000”.  For example hip replacements surgery via the MBS Schedule fee is $1317.80. Medicare ie the government, via your taxes, contributes 75% of this ie $988.35. Your health insurer, for example the insurer Medibank  is required to pay the remaing 25%, ie $329. If you surgeon agrees to “No Gap” or “Known Gap” (nothing out of pocket, or up to $500 out of pocket), Medibank will reward the surgeon by giving them a % top up. Currently, the total payment from Medibank for a No / Known Gap hip replacement is $2000; this is made up of $988.35 from Medicare, and $1112 from Medibank. That payment is then expect to include follow up afterwards; by convention this is usually 12 months.

So, to summarise in my practice (Dr Shooter), I will charge a “No Gap” and “Known Gap” for hip replacement surgery with Medibank (again using Medibank as an example only) . So when it actually comes to my cost and estimate “Out of Pocket” costs related to surgery then a patient can expect to pay $0 up to a maximum of $500.  Now another surgeon may not participate in “No Gap or Known Gap” billing with Medibank.  This is when patients can be billed hundreds or even thousands of dollars out of pocket.  Therefore it is important for patients to understand the options, research and be very well informed.

Dr David Shooter offers “No Gap” and “Known Gap” billing to all patients privately insured with Bupa, HCF, Medibank Private or the AHSA group (eg TUH, Navy, CUA, Credicare etc).  Additionally, patients that do not have private health insurance but wish to have surgery privately with Dr Shooter can now apply to ZipMoney for interest free and flexible payment options*.  All patients will require a referral to see Dr Shooter.  Contact us today with any questions.

*Conditions apply to patient wishing to access ZipMoney, click here to learn more.

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