Public and private
Treatment as a public patient in the NSW public health system is provided at no cost to you. This includes treatment as a public patient in a public hospital and at community health centres. Some people may also be eligible for treatment at public dental clinics, or ambulance services, at no cost.
If you see a doctor or other health service provider privately, there will be a charge.
Costs in private health care
The government does not regulate fees charged for health care services by private health providers (for example, doctors, dentists, denture makers, optometrists, physiotherapists and podiatrists, etc). Private practitioners, private hospitals, day surgeries and nursing homes can decide what they will charge for their services in the same way as any other business.
Some health providers have professional associations, such as the Australian Medical Association (AMA), that suggest ‘recommended’ fees. But, doctors are not obliged to charge this fee – they may charge more or less.
The Medicare Benefits Schedule
For many health services, the government sets a Medicare Benefits Schedule (MBS) fee, often referred to as the schedule fee. Medicare pays a percentage of this fee – this is called the Medicare benefit. It is not an indication of how much your doctor can or should charge you, but it is usually less than what the doctor will charge you.
Most medical services attract a specific Medicare Benefits Scheme item number.
Services not covered by Medicare
Not all health services or procedures attract a Medicare benefit. For example, Medicare does not cover most private dental services or physiotherapy. A person treated by ambulance officers is responsible for paying any fees associated with their treatment and/or transport, regardless of whether or not they were the person who requested an ambulance.
Know the full costs
If you have private health insurance, you should seek information about what your private health fund will cover and what you may have to pay yourself (the gap). Before you contact your health fund, please ask your doctor or provider about:
- the most likely Medical Benefits Scheme (MBS) item number to be used
- the name of the hospital or facility where the procedure will be performed
- the charges of all attending doctors
- the charges for tests, such as pathology or x-rays.
With this information, contact your health fund to ask about the full costs and any gap that may apply. The gap is the difference between what the practitioner charges and what Medicare plus your health insurance will actually cover you for. It is often called your ‘out of pocket expenses’.
What is bulk-billing?
A doctor can choose to charge a patient only the Medicare Benefit amount – this is called 'bulk-billing'. The patient signs a form assigning the Medicare benefit for the service to the doctor, the doctor accepts the Medicare benefit as the total payment, so there is no additional charge to the patient.
A doctor has the choice to bulk-bill all patients, no patients or some patients. The doctor may choose to only bulk-bill for some services.
Avoid unexpected costs
Ask about the cost first
The best way to avoid unexpected costs for health care and treatment is to ask first. Ask how much the service will cost if you have not been told. If you agree to a service without asking about costs and charges, it is difficult to complain after you have received the service.
Clarify and confirm the total costs
You have a right to know what the costs will be. Wherever practical, a health care provider should be prepared to discuss charges with you before providing the services. If it is more complicated, you can ask for written information about the costs.
- If you are given an 'estimate' of the cost, it might vary if there are unexpected complications.
- If the care is to be provided in a private hospital, you should also ask about hospital and other charges.
- It is best to have any verbal quotes confirmed in writing. Some health providers request payment prior to treatment. You may also be charged a cancellation fee, if you miss your appointment.
Cost for other services
Be aware that there may be other practitioners involved in your care also expecting payment. Examples of these might be the surgeon’s assistants or anaesthetists. Your doctor or other health service provider should be able to tell you who will be involved in your care, and how to find out what other providers can charge.
Always keep in mind that the cost quoted could increase if there are complications in your treatment. For example, your surgery may be unexpectedly complex, or take longer than anticipated.
When your health service provider gives full explanations about the fees and you agree to go ahead with the treatment, you are giving 'informed financial consent'.
How to deal with surprises
If you are asked to pay for something you were not expecting, or your bill is substantially higher than what had been discussed, the first thing you should do is discuss the situation with your health care provider. Sometimes there might have been a misunderstanding or error in the bill. The provider will not know that you have a problem with the fees unless you let them know.
If you are dissatisfied with the response
If, after speaking with your health service provider, you still feel that the charge is unfair or unreasonable, you need to communicate this, preferably in writing. It is better to deal with the matter rather than withholding payment, as the health service provider may decide to put unpaid bills in the hands of a debt collection agency. It may be possible to negotiate an agreement on how to pay the account, for example, by instalments.
If you are a member of a health fund, contact the Private Health Insurance Ombudsman (PHIO) on 1800 640 695. PHIO also produces a useful brochure called 'Doctors Bills' which provides more detailed information on this topic.
If you are seeking a refund for goods (for example dentures, glasses, orthotics), which are faulty or for a service you feel you did not get what you paid for, contact the Office of Fair Trading on 13 32 20.
If you are concerned about overservicing or the correct use of item numbers, contact Medicare Australia on 13 20 11.
If you are dissatisfied with the clinical care provided, rather than the cost of the care, contact the Health Care Complaints Commission on 1800 043 159 (toll free in NSW) or 9219 7444.