The Australian health system in complex and bureaucratic. This is especially true of the billing system. Your fees for medical and surgical treatment depend on a number of factors including:
Whether you are covered by Medicare.
Whether the procedure is covered by Medicare.
Whether you have private health insurance.
What level of private health insurance you have.
Where you have your treatment or service provision.
Most people in Australia have a Medicare card and are thus covered by Medicare. If you are not sure if you are covered by Medicare you should contact Medicare Australia and ask them.
To give an example of the complexity of the billing system, a patient with varicose veins will be used as an example.
If you have varicose veins and want to have them treated you will first need to see your general practitioner (GP). Most GP’s will bulk bill patients but some do not and so there may be an out of pocket expense (gap) for obtaining a referral to a specialist.
Varicose veins are best treated by a vascular surgery specialist. You should ask your GP to refer you to Stuart Walker. If your GP refers you to Stuart Walker at one of the public hospitals in Tasmania, (Royal Hobart Hospital, Mersey Community Hospital, Launceston General Hospital) an appointment to be seen in the outpatient clinic will be sent to you once Stuart Walker has received the referral letter. Because of the long waiting times for outpatient appointments in public hospitals it may be some time before you are seen in the outpatient clinic. When you attend the public hospital outpatient clinic, you will be bulk billed, with no out of pocket expenses.
If your GP refers you to see Stuart Walker as a private patient at the Calvary Consulting Suites or the North West Private Hospital you will be seen sooner but there will be some out of pocket expenses. The first consultation fee (Medicare item number 104) at the Calvary Consulting Suite is $150.00, of which you can claim $72.75 back from Medicare. The first consultation fee at the North West Private Hospital is $160.00, of which again $72.75 can be claimed back from Medicare. These fees will need to be paid on the day of the appointment by cash, debit or credit card. If you have private health insurance you may be able to claim back more of the fee.
All patients who will be having treatment for varicose veins need to have an ultrasound scan of the veins in order to plan treatment and assess the best option for treatment. Some organisations which perform ultrasound scans will bulk bill patients (no gap) but many will charge a gap. Stuart Walker will be able to provide advice on which organisations he recommends for the ultrasound scan based on a balance of any gap payment and the quality of the scan and report. If your GP has not requested a scan, do not worry as Stuart Walker can do this but it will mean another visit to Stuart Walker for a follow up appointment to discuss the scan result (Medicare item number 105). The fee for the follow up appointment will be $60.00 payable at the appointment. Again, some of this can be claimed back from Medicare or your private health insurance company. See the conditions tab for more information on the treatment options for varicose veins.
If it is recommended and you agree to have treatment for varicose veins as a public patient in a public hospital, there will be no out of pocket expenses. But remember that the Tasmanian Department of Health and Human Services have placed strict criteria on who can get treatment for varicose veins in the public hospital. There can also be long waiting lists for surgery in the public hospitals.
If it is recommended and you agree to have conventional varicose veins surgery as a private patient in a private hospital, there are a number of components to your overall fee.
Surgeon’s fee. It is a policy of Stuart Walker that he does not charge any gap for surgical procedures. So if you have no private health insurance, you will be bulk billed via Medicare at the Medicare rate. If you have private health insurance, you will be billed through your private health insurance company at the no gap rate. Medical insurance companies place different values on the surgeons time and skill and so the amount paid to the surgeon will vary from one insurance company to another. Be aware that many surgeons do charge a gap. They will have a set fee for a given procedure, often well in excess of the Medicare or private health insurance company rebate. So despite having private health insurance, there may still be a gap for you to pay for the surgeons fees. You should always clarify the fees with your surgeon before any operation.
Anaesthetist’s fee. You should always ask the anaesthetist before the operation what the fee will be for their service (financial consent). The anaesthetists at the North West Private Hospital will bulk bill patients and so there should be no out of pocket expenses. Again, this fee will be variable dependant on your health insurance status, level of cover and the insurance company.
Hospital fees. You should always ask the hospital for a quote for the hospital fees for any operation. In order to quote a fee for you, they will need a Medicare item number from the surgeon. For most single leg varicose veins operations this is 32508. The quote will also need to take into account whether you will be operated on as a day case or whether an overnight stay will be required. Most varicose veins operations are performed as a day case. Unfortunately none of the hospital fees can be claimed back from Medicare. The hospital fees thus represent your biggest outlay for surgery. If you have private health insurance, most of the hospital fees will be covered by your insurance company, depending on the level of your cover.
2015 update - Medicare have deemed that some treatments for varicose veins are not classified at surgical but as medical procedures. This means that medicare or your private health insurance company will not pay the hospital fees for some forms of varicose vein treatment. You should clarify this with you private health insurance provider.
Pathology fees. If you need to have blood tests before or after the operation, the pathology organisation will bill you for these tests. Most pathology companies will bulk bill but some do not.
Medical imaging fees. If you require medical imaging before or after your operation, the medical imaging company will bill you for these tests. These organisations do not always bulk bill and so you should ask before any medical imaging test what the fee will be.