How Much will the Operation/Procedure Cost?

So you have been referred to a Specialist and you need a procedure to diagnose the problem or an operation or procedure for treatment.

What is it likely to cost?

Before Hospital Costs

There are often Out of Pocket costs for the initial consultations with the Specialist, ( SeekMedi often shows the Specialist's consultation fees, but you need to register) and for tests, eg X-rays, Pathology etc.

These are not shown by My Dr Bill.

Procedure Costs

The costs involved are as follows (not all of these apply in all cases)

  • The Specialist performing the procedure
  • ‍The doctor assisting the specialist (if needed)
  • ‍The anaesthetist
  • ‍Xrays or scans
  • ‍Pathology
  • ‍Hospital/day centre fees
  • Physio / rehabilitation

Hospital / Day Centre Costs

If you have private health insurance (PHI) your provider will cover some or all of these costs provided the procedure is included in your policy. You may have an upfront payment as part of your policy so make sure you check the details of your policy and call your PHI provider if you are not sure.

These will be billed by the hospital to your PHI and to yourself if you have an upfront moiety.

Specialist Fees

Specialists are free to charge whatever they think their work is worth.

There are three parties who contribute to the Specialist fees if you have PHI:

  • Medicare funds 75% of a set price for the procedure (the Medicare fee is set by Government).
  • ‍Your PHI will fund part of the fee (how much is quite complex and will be explained below).
  • You may be asked to contribute as an Out of Pocket cost that cannot be claimed back from Medicare or your PHI.

PHI Contribution to Specialist Fees.

This has become a very complex system in which the full fees paid to the Specialist are often not seen by the patient, the PHI fund or the government.

If your Specialist has an agreed arrangement ( No Gap or Known Gap) with a health fund  where the Specialist  charges a patient an Out of Pocket cost of no more than an amount set by the PHI eg $500 (the amount varies with each fund), then the PHI pays the Specialist the total of the Medicare fee (100% of the Medicare fee)  plus an agreed extra amount eg 40% of the Medicare fee and then gets the money back from Medicare for the 75% of the Medicare fee. In this case the patient pays an Out of Pocket cost between $0- $500 depending upon the specialist’s decision in each individual case.

If the Specialist charges the patient more than the agreed amount (eg more than $500 in the case above) then the PHI only pays the Specialist 100% of the Medicare fee. The patient would then  be expected to pay the additional cost of the 40% of the Medicare fee as well as the $500 (or more) Out of Pocket cost.

Often now however Specialists are sending separate bills to the health fund and to the patient.  This means that the PHI do not always know the full charge the patient is paying out of their own pocket. It appears to the PHI as if the Specialist is charging no Out of Pocket costs when in fact these fees can often be very high. Because the PHI thinks the doctor is not charging any out of pocket fees then they pay the doctor as if it was a No Gap arrangement ie in the above example 140% of the Medicare fee. The patient however may be paying thousands of dollars out of pocket.

The solution to this issue is very tricky. If patients advise their health funds about the high Out of Pocket costs, they may end up having to pay even more to the Specialist.

Before you engage a Specialist you should know what your likely Out of Pocket costs are likely to be. Look at our Out of Pocket costs data.