I have chronic pain for which I need semi-regular physiotherapy, and have stuck with my current insurer partly because they give good service but also because they have their own affiliated suppliers of physio with a “guaranteed gap”. It started at $10, crept up to $12, then $16, and currently sits at $18. In my (20ish) years of experience at other practices, I have never been charged any more than the gap stated by the insurer. Having moved house, I found another affiliated provider, but have found that they whack on an extra $15 for their “senior” practitioners, and in fact I think that the first time I went, was an extra $30.
What do you think of this? Should I complain to the insurer? (I am wondering now whether gaps would be more than $33 at other physio practices nearby…)
Guaranteed Gap also called known gap is where medical practitioners charge a gap which is disclosed to a patient before services are provided. The gap is ‘guaranteed’.
This is different to ‘no gap’ where a medical practitioner only charges the schedule fee associated with the service, meaning there isn’t any gap.
As medical practitioners charge gap fees, they are responsible for setting the gap, not the insurer.
I expect your health insurance provider will have information about the ‘gap guarantee’ and how it works. It would be worth reading this.
If for example the medical practitioner indicated a gap of $20 before the service was provided, but after the service was provided said the gap was $30, this is unlikely to meet the requirements outlined by the health insurer. In such circumstances, a complaint to the health insurer is warranted.
If the disclosed gap was say $20 last year, but has gone up to $30 this year, and the gap outlined before the services was the same as that paid thereafter, this is the responsibility of the medical practitioner. If one is unhappy with the increase in gap (out of pocket expenses), one can raise one’s concerns with the medical practitioner. Complaining to a health insurer won’t be a fruitful exercise as the health insurer will say it is up to the medical practitioner to set their own gaps.
If you are unhappy with the gap, and other physios can provide the same service, I would be shopping around to see what others offer and the cost. It is important one checks the service is exactly the same, including consultation periods.
One isn’t obliged to use affiliated suppliers. When shopping around, tell the physio the health insurance you have so that they can confirm out of pocket expenses, where they exist.
Choice also has useful information as well:
I think that this is different though. These are private practitioners, unrelated to anything provided by Medicare, and this particular insurer advertises widely to sell its insurance based on the guaranteed gap…
I have just checked my actual policy document, which states, for follow-up physio visits at their affiliates, “pay only $18” (initial consults, it’s “pay only $22”).
Would you post your policy? If you are in one of the funds with network providers it is different when one goes to an out of network provider. Could that be it?
I also go to a physio where the ‘seniors’ in the office have further qualifications and training, and higher fees than the rest at that practice.
You might also be aware that if your GP makes a referring ‘treatment plan’ medicare will pay a fixed amount toward up to 5 physio visits, limited to one plan per annum.
A caveat is one only gets the medicare or the extras, not both.
Yes, thank you - I do get the Medicare ones as well.
Mine is a legacy product and not exactly the same as what they offer in their new products, but I think I’ll phone them tomorrow just to clarify. (And will post my policy if I get to the computer tomorrow.)
