Out-of-pocket medical bills need no longer be a surprise

Want to do a price check on out-of-pocket medical expenses? Now you can.

Take the bill shock out of surgery

Outrage after a Four Corners exposé revealed that some medical specialists pocketed exorbitant fees not covered by Medicare or private health insurance has turned into action.

The report elicited swift criticism from key medical bodies with calls for a royal commission, greater transparency of fees and a limit on doctors’ current freedom to set whatever prices they want. Now, for the first time, patients have some degree of control – they can check how often a surgeon or specialist has used a private health insurer's gap cover scheme and gauge any out-of-pocket costs.

Online medical directory Healthshare has published gap scheme participation data on the profile pages of more than 14,000 specialists across Australia, Fairfax is reporting.

“For example, a Teachers Health Fund member referred to a particular orthopaedic shoulder surgeon in Sydney would be able to see that four per cent of 124 patients who received in-hospital treatment in the past 19 months paid no gap, 26 per cent paid a known gap, and 70 per cent paid an out-of-pocket cost of more than $400,” the report says.

Thirty health funds that are members of the Australian Health Service Alliance or Australian Regional Health Group, as well as Medibank and HCF, contributed to this information on Healthshare.

Three funds – Bupa, HBF and nib – opted not to make their data available.

A Bupa spokesman told Fairfax it had "led the way on providing transparency of out-of-pocket costs to our customers through our online tools [and] have partnered with a number of providers".

Patients needing specialist medical treatment have traditionally accepted their GP’s referral. But given there are sometimes huge variations in specialists’ fees, questions are being asked more regularly.

Healthshare CEO Rami Weiss said: "GPs don't have a lot of this [pricing] information and it's not realistic for them to search around fund by fund, so we're putting it at their fingertips.

"We want patients to have better discussions with their GPs and specialists, to take the information, understand their situation and know what questions to ask.

“We've also seen specialists say they've been tainted by a few outliers [who charge too much], so we're also allowing specialists to provide information themselves on fees on their profile.”

The Australian Medical Association (AMA) tweeted after the Four Corners program: “No Australian should need a GoFundMe page to afford their medical care. It may only be a small number of doctors charging egregious fees, but it needs to stop.”

AMA president Dr Tony Bartone said: "We're concerned about egregious billing, but prices can vary depending on what state you're in, whether it's CBD or rural, and on the patients – there's undercurrent illness, intercurrent conditions, complicating factors.”

"The out-of-pocket committee is looking at the issues and whatever the solution is, it must be tested and evaluated to make sure it gives meaningful, informed and reliable outcomes, and that there are no unintended consequences."

Royal Australasian College of Surgeons (RACS) president John Batten said the majority of Australian surgeons aimed to deliver affordable quality care, but that a small number of ‘rogue operators’ were charging excessive fees in breach of the RACS Code of Conduct.

Grattan Institute health economist Stephen Duckett said Healthshare, in which Fairfax has a minority holding, was responding to consumer need.

"It's good the consumer can look at what the out-of-pockets are likely to be and then talk to the GP again and say, 'Hang on, this person seems to have high out-of-pockets, is there someone else?'" he said.

"But one critical risk is that people will think out-of-pockets is the only criterion, when quality of care [and] complication rates are important factors."

Have you had experience with unexpected out-of-pocket medical expenses? Would you ask the question and shop around? 



    To make a comment, please register or login
    26th Jun 2018
    I waa in the process of moving health funds when I was assessed for shoulder surgery. My ‘known gap’ from HBF was $1,400. I moved to HCF and my ‘known gap’ was $500. Imagine how shocked but happy I was? This is the type of information consumers need to know.
    Bupre, HBF, NIB opted not to make their data available. I wonder why?

    26th Jun 2018
    The whole health profession, including the medical insurance industry, needs a Royal Commission into it.
    27th Jun 2018
    Absolutely, there are too many issues.
    Private Insurance must pay expenses in full with No Gaps (other than any agreed excess and the Medicare 15% of Scheduled fee) - they met bear the RISKS of all costs, not patients!
    Doctors fees are FIXED by collusion through their Union (ACCC should have looked at this decades ago and stopped it) - there needs to be competition, with a limit on the Maximum they can charge above Medicare Scheduled fees.
    Govt also needs to set realistic Scheduled Fees.
    Publishing doctors fees should be a no-brainer, it is last century thinking to object to it. Of course, other factors should also be included in such a web site, so patients can see the full picture.
    26th Jun 2018
    Sounds good. How do I access this info. to check on specialist gap payments ?
    Yeah, right!
    26th Jun 2018
    Well Stoudie,

    That's the issue here. Clearly Healthshare has put out a press release following the 4 Corners report. They are a month late but that's not bad for an underfunded govt dept - don't doubt the good intentions driving the staff but lack of proper government support in the budget simply shows the level of care of governments at state and federal levels. Here's a couple of points

    Firstly, the quality of the site is way below acceptable standards - e.g. having people use post code as a search crition when looking for a specialist is 'pre-kindergarten' coding. A very clear example of their inability to understand their potential users.

    Secondly, I tried to look up the gap that my Dermatologist of 30+ years standing in the professional and not ONE of the funds in Healthshares drop-down list had ANY history of claims - zero, zip, NOTHING. Do I doubt the bona fides of the data they hold?

    Thirdly the sites are full of motherhood statements and THE LIKE, BUT nothing of real value for consumers. Is this another ATSIC in the making?

    Just a further example of governments directives to "feed them cake".

    Finally, any organisation that receives a 'press release" and publishes it, unquestioningly, without attempting to confirm the claims made shows as much contempt for its readers as some medical specialists show to their patients in this day and age.
    Trust their advertisers will be watching. We are!
    2nd Jul 2018
    Haha Yeah Right. Took me back to the 80s and 90s when sitting around making up motherhood statements and vision statements and changes to names and fancy abbreviations was done to death.
    Life experience
    26th Jun 2018
    It’s not just the surgeons that need to be looked at. It’s also the Anaesthetists out of pocket expenses.
    26th Jun 2018
    Why not have a Royal Commission into not only doctors and specialists, also INCLUDE DENTISTS who are the worst at charging exorbitant fees
    26th Jun 2018
    My wife recently had a bowel operation. I had checked up whether the surgeon participated in my health fund's "no gap" scheme and he did. At the last meeting with him prior to the operation he told me there would "out of pocket fees", but I would not have to sell the house to pay for them. This was after I told him I was an age pensioner. The point being that even though he participated in the "no gap" scheme sometimes, he did not always do so. By this stage my wife's condition was so bad it was too late to look for another doctor. The upshot was that on top of expensive fortnightly payments for private health cover I had to fork out an extra $2,200 for a doctor who sometimes participated in the "no gap" scheme. What is the point of private health cover? Specialists need to be forced to publish their fees, that way they might be shamed into being reasonable.

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