Before you receive your treatment you are entitled to ask your doctor, your health fund, and your hospital about any extra money you may have to pay out of your own pocket, commonly known as a ‘gap’ payment. Knowing how much your treatment will cost is called Informed Financial Consent.

  • Ask your treating doctor or specialist wherever practical how much their fee will be, and if you will need to pay a gap. For major treatment this information should preferably be provided in writing.

You may have more than one doctor involved in your treatment, for example, a surgeon and anaesthetist. Your surgeon should be able to advise who else will be treating you and how you can contact the other doctors to seek fee information from them.

You may have lower or no out-of-pocket medical costs if your treating doctors elect to use your health fund’s gap scheme. You are entitled to ask your doctors if they will use your fund’s gap scheme.

  • Ask your health fund whether your policy will cover the procedure, and whether you will need to pay an excess, co-payment or any other charge associated with the treatment. Your health fund may need you to obtain the Medicare item numbers your doctor will be using to give you an accurate quote. If you are within waiting periods, you will also need to ask your doctors to fill in medical certificates for assessment by the fund of whether benefits will be paid.
  • Ask the hospital whether they have an agreement with your private health fund and whether you will have to pay any gaps or extra costs. Your hospital should perform a membership eligibility check with your health fund before you are admitted and seek your informed consent to incurring any out-of-pocket costs associated with your admission. This information should preferably be provided in writing.

What can I do if my bill is much higher than I expected?

We suggest you first check whether you agreed to these charges before treatment, and contact your doctor’s office to discuss the reasons for the various charges.

The Private Health Insurance Ombudsman produces a brochure about medical fees, which is available on our website.

IFC in Emergency Situations

There will be circumstances, for example emergency admissions, where it will not be possible for your doctor to obtain IFC before the service is provided. In that case, information should be provided to you as soon as possible after the service is provided. In circumstances where it’s not feasible to provide information directly to you before or after treatment, your doctors may provide the information to a near relative or representative acting in your interests.

Making A Complaint and More Information

If you are unable to negotiate a suitable outcome with your doctor, you may wish to contact the Private Health Insurance Ombudsman on 1300 362 072 or via this website for assistance.

You can also contact our office for general information about private health insurance and to compare health insurance policies.