Thank you for posting this in the community.
This bill is an example of bad practice. On top of charging an extremely high late fee, it is very confusing and contains a major error
The anaesthetist has written the bill in a very confusing way: it says in the difference between 1249.40 and 749.40 is $750.60 which is wrong - it’s $500.
It also doesn’t make sense if you do not explain that the health fund’s gap scheme has been used and may breach health insurance rules for gap schemes
How gap schemes work
For privately insured services in hospital (like anaesthesia), Medicare pays 75% of the MBS fee and the health fund pays 25%. So as soon as the provider charges more than the MBS the patient pays an out-of-pocket cost, called gap.
To reduce the amount of the gap and reduce the number of patients charged a gap, health funds use gap schemes. Under these gap schemes, health funds pay more than 25% of the gap up to a capped amount.
Bill may be in breach of known gap scheme
The heading of the bill shows that the health fund’s “known gap scheme” has been used. Under the known gap scheme a provider can charge an amount up to the cap set by the health fund and usually can charge the patient an out-of-pocket fee of up to $500.
Therefore, if the anaesthetist charges the patient 750.60 - as they threaten to do if the patient does not pay $500 within two days after receiving the bill - they also have to give a refund to the health fund.
If they do not give the health fund a refund they may actually be acting illegally. It is also not in the spirit of a known gap scheme to not provide financial consent before the procedure and put the patient under pressure after the procedure.
Lodging complaints
I would suggest lodging a complaint with Commonwealth Ombudsman (PHIO) about the confusing way in which the bill is written including the potential breach of gap scheme rules.
If something similar happens to anyone else, the best first step is to call the provider and negotiate more time for paying the lower fee.
We’d also love to hear about it, please don’t hesitate to contact me on healthinsurance@choice.com.au
