Surgeon Fees and 'The Gap'

Dr Finch’s Fees

If you have private health insurance, most of the costs of your surgery will be covered. However, you will still have to pay a gap for the medical fees.

How much will I be charged for my operation?

The fee you are charged by your surgeon depends on the length and complexity of your surgery. The fee charged is based on the recommendation of the AMA (Australian Medical Association) and will be approximately equal to the AMA fee.

How much will Medicare cover?

The Medicare Benefits Schedule (or Schedule) is a list of operations which is compiled and updated by the Commonwealth Government. Each operation is allocated an item number and a fee. It is not a recommended fee. It simply represents the amount that the government, having regard to budgetary and economic considerations, is willing to pay. The Medicare rebate is the amount that you can claim back from Medicare and is 75% of the Schedule fee for in hospital expenses such as operations.

Why is there a gap between the surgeon’s fee and the Medicare rebate?

There are two reasons why there is a gap between the surgeon’s fee and the Medicare rebate:

  • There is a 25% gap between the Schedule fee and the Medicare rebate
  • There is a gap between the Schedule fee and the surgeon’s fee

The Government Schedule was established in 1985. Unfortunately, the Schedule has not increased in line with inflation and the cost of running a practice. This is why most doctors charge more than the Schedule fee, and why the gap between the fee and the Medicare rebate continues to increase. The Schedule also does not necessarily reflect new, more complex procedures and techniques.

How much is ‘the gap’?

The gap depends on:

  • the operation you are having
  • which health insurance fund you have cover with
  • whether your surgeon chooses to use the GapCover arrangement of your health fund

GapCover allows your health fund to cover some of the surgeon’s gap leaving you with a smaller co-payment but restricts the amount the surgeon can charge.

What does my health insurance cover?

Your health insurance covers the majority of the costs of your operation. Most health funds have agreements with the Sunshine Coast Private Hospital – Buderim.

Apart from any excess your policy may have, your health fund covers your hospital costs, including bed fees, theatre fees and the cost of implants and prostheses. Please contact your health fund directly if you have any questions. The Privacy Act restricts the information this practice can request on your behalf. Your health fund covers the 25% gap between the Schedule fee and the Medicare rebate. In some cases, it also covers part of the gap between the Schedule fee and the surgeon’s fee, depending on whether your surgeon participates in your health fund’s GapCover scheme and whether he chooses to use it for your particular procedure.

Will I be informed of the costs?

Our practice provides informed financial consent before your operation. You are informed of the surgeon’s fee, the item numbers used and the out-of-pocket gap. In some cases, the actual procedure performed is different to that quoted for, but your out-of-pocket gap will not change. You will also be given the names and contact numbers for other doctors and providers involved your operation so that you can contact them for an estimate of their fees.

How will I be billed?

If you pay the total fee prior to surgery, the fee will be reduced by $300.

Alternatively, if you choose to only pay the gap at the preoperative appointment, the $300 concession does not apply. You will be billed for the remainder of the cost after surgery. It is your responsibility to submit the invoice to your health fund and Medicare, and then to forward the cheques to Dr Finch immediately upon receipt.

In the case of some of some smaller procedures, Dr Finch will participate in your health funds GapCover scheme. This means that you will only have to pay the gap at the time of your pre-op appointment and after surgery the balance of the account will be sent directly to your health fund.

What if I don’t have health insurance?

You will receive a Medicare rebate which is 75% of the Schedule fee. You will be responsible for the rest of your costs, including the Schedule gap, the surgeon’s gap, the theatre and bed fee, and the cost of any prostheses, implants and consumables used, as well as fees from other doctors and providers involved. This can add up to many thousands of dollars. We will attempt to provide you with an estimate of these costs. If you cannot afford this, you can seek treatment in a public hospital or take out health insurance and wait the 12-month waiting period before you are eligible for benefits.