Specialist Fees – How do they work?
Specialists charge consultation fees for appointments in their rooms and these are usually higher than the Medicare rebate. The web site Seekmedi provides information about consultation costs (remember to register on the site to see the fees charged).
At the first visit, Specialists often order tests such as pathology or imaging (Xrays, CT scans or MRI’s). Imaging procedures often have significant out of pocket costs.
Consultations and tests ordered from rooms are NOT covered by Private Health Insurance (PHI).
For procedures (operations, colonoscopies, angiograms etc.) you will normally be admitted to a hospital or day procedure centre. The Specialist’s fees, pathology tests and imaging ordered in hospital or day centre as well as the hospital costs (or Day Centre) are covered by Private Health Insurers.
Specialist's fees for procedures are paid by a combination Medicare, PHI and Out of Pocket costs. (Out of Pocket costs are fees that the Specialist charges which are not covered by Private health insurance.)
PHI funds have gap cover arrangements with many Specialists and believe these prevent Out of Pocket costs, but Specialists may send separate bills to the fund and to the patient. Thus funds are often not aware of the Out of Pocket costs.
Most procedures will involve a main Specialist, and others such as anaesthetists, assistants etc. all of whom charge fees.
Funds will often explain to their members that if the Specialist has a gap agreement with them, then Out of Pocket costs will be zero or small. However, these arrangements are not truly binding and are often not applied to individual patients. Booking fees and other Out of Pocket costs are not covered and the funds have no knowledge of them.
The only way to find out what the Out of Pocket cost for the procedure is likely to be is to ring and ask the Specialist's receptionist and whether there will be other doctors (assistant, anaesthestist etc) also charging Out of Pocket costs.
The main Specialist will usually give a written quote for his/her services but it is often difficult to find out in advance what the other doctors will charge.
HIGH COSTS DO NOT NECESSARILY MEAN HIGH QUALITY OUTCOMES.
If costs are an issue, think about choosing a public hospital.