Bupa silver + hospital cover -out of pocket expenses $3100 of $4500 bill (operation only) not including anaesthetist, tests, scans or specialist appointments etc.) for wife’s breast cancer surgery. Medicare $1000 approx. Bupa ‘Hospital cover’ $ 400. Yes …the room only, not the doctor or surgery. Be very careful what you think ‘hospital cover’ actually is. We were not prepared. Fair to say Bupa ‘Hosptial cover’ relies on your specialist being ‘signed up’ to the Bupa gap scheme. Even then there are still significant out of pocket expenses. Out of pocket tool - worth checking prior to any private hospital surgery … alternatively (preferable) choose another health insurance provider.
For clarity would it be correct that neither or either of the surgeon or the hospital were in the BUPA network? Or were those out of pocket with using their in-network providers?
Hospital is a Bupa network hospital. I checked these fundamentals and medical conditions etc. that were excluded from the hospital cover prior to admission.
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The very next visit to the surgeon / specialist my wife was fundamentally ‘bullied’ by the receptionist to pay the full bill with her card then seek both medicare and health insurance remibursement herself.
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The AMA, essentially the doctor’s union, is not exactly unbiased or just community minded since it primarily looks after its members, but many interesting points have been made.
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On one hand the AMA is saying,
In 2022-23, the amount of money returned to customers from hospital insurance policies fell by 81.6 per cent in 2022-23.
On the other the ACCC annual report to the Senate on the performance of the Private Health Insurers notes:
Referring to any comparisons relative to the period 2019-2022 can provide abnormal results due to Covid impacts on consumer use of private cover.
I can’t reconcile the AMA statistic to what the ACCC has reported for the previous 4 years for the total value paid out by insurers for hospital claims. The total amount paid overall has increased over the previous 5 years.
Start here.
‘Private health insurance report 2019-20 | ACCC
P.S.
Perhaps the AMA is trying to say something else about refunds for hospital cover?
This is an old thread, but my complaint kind of relates to it. AFAIK, there is no health insurance that covers out-of-hospital services such as ultrasounds, and I have experienced enormous disparities in what I have paid in gap fees. Some charge nothing, or a trivial admin fee, but the one I had yesterday - a 5-minute procedure - charged $224 full fee, of which I got $104 back from Medicare. This seems just outrageous.
That is correct:
These are generally covered by Medicare (where it meets Medicare requirements), and refunds are determined by the Medicare Benefits Schedule rate. Providers can charge more than the schedule rates, meaning one is out of pocket the difference. This is what you have experienced.
It is worth noting that some providers will bulk bill, if requested in the referral from the doctor. It is worth asking when the referral is prepared if such wording be added in hope the provider bulk bills.
I expect that scans, other than when an admitted patient, is to prevent ‘double dipping’. That being one makes a claim under Medicare and health insurer, such that the same benefit is paid by both.
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Our experiences for various imaging services vary. My GP is very good in advising whether a particular imaging requirement is included in a Medicare schedule, and if I qualify. There are rules. Further as you note not all imaging services charge the scheduled fee. One is free to shop around and ask. I’ve done this recently preceding imaging of a damaged joint, and found one service which had no out of pocket costs.
I’ve assumed the reason OoP costs for imaging other than when admitted for treatment are not covered by private insurance is also a cost control measure.
For those of us a little older having a concession card can also assist with some services or providers. The Commonwealth Seniors Health Card is available to those who are self-funded and can meet the qualification requirements.
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An interesting observation?
Our experience is the private health insurer is fully aware of which services (by code on the invoice/payment receipt) are eligible for a Medicare refund and the amount. The fund will take that amount into account if there is gap cover provided. We’ve made claims using the provider’s at counter system (optical services being one example) as well as online claims supported by digital copies. It’s not evident how one might be able to double dip.
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Medicine is a business. What you are experiencing is price differences just like patronising any other business. One aspect that sometimes gets missed is whether the referring doctor ticks the ‘bulk bill’ box. Specialists, especially, do not always do that and some do not do that unless asked, and some will not do it at all. Some referral forms inexplicably do not even have the box and the doctor has to write ‘please bulk bill’ on it. Sometimes it gets overlooked and a full fee is charged.
Is it possible the bulk billing box was not ticked on that last one?
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There are items which are charged/claimed differently and not claimed under Medicare and health insurance.
Services relating to testing eye health (glaucoma, cataracts, macular diseases) have items under the Medicare schedule and covered by Medicare up to the scheduled rates. Provision of glasses isn’t covered by Medicare, but can be covered by health insurance. One shouldn’t confuse that both aspects are covered by Medicare and health insurance.
Not only the risk of double dipping, but covering scans by Medicare and a gap by health insurance will likely cause price of the services to increase, as providers know a significant proportion of patients will be able to afford to pay more, since there are two benefits being paid for the same service.
According to Services Australia there are various instances where one can claim both a Medicare benefit and from a Private Health fund.
As noted in your prior link to Services Australia on making claims which includes “Medicare Two-Way”.
There are times when you can claim Medicare benefits and use your private health insurance at the same time. For example, you go to a public hospital as a private patient. You may be able to claim the costs we cover from us and some or all of the other costs through your private insurance.
This means you’ll need to claim from 2 places for the same bills. You’ll need to submit a Medicare claim form and a Medicare Two-way claim form.
If you submit your forms to us, we’ll pass on your insurer’s share to them. If you submit your forms to your insurer, they’ll pass on our share to us.
“Double Dipping” in common legal usage refers to receiving a benefit one is not entitled to. Is this a common occurrence where those holding private health insurance are receiving a cash payment they are not entitled to? Where we’ve made claims on private cover and it has not been processed by the service provider on the day, our insurer has required a copy of the original bill. The Health insurer know’s whether the service (by service type number) is covered by Medicare. It’s not evident how one could double dip any personal claim, especially considering most funds and Medicare participate in Two-Way processing.
There are independently issues where some public hospitals have been double dipping the system when treating private patients, to the hospitals benefit.
To consider also where Health insurers have nominated or preferred service providers there can be additional services included at no extra cost that are not covered by Medicare. One does not need to claim - however in the words of one.
It pays to take time to look at the options and make an informed decision as to where the best value lies relative to ones circumstances and needs.
That is correct, and the hospital admission costs for a public hospital. It was a deal a past government did with insurance companies as part of the premium co-contribution/subsidies for health care. The payment is a contribution towards the public health system (viz. a private patient in a public hospital). This website shows who pays what when admitted to public hospital with private health insurance.
Double dipping is also claiming for the same think twice:
Double Dipping: Making Multiple Claims for Total and Permanent Disability (TPD) - Roche Legal.
An example being, one has travel insurance associated with their credit card and had also taken out a separate travel insurance policy. Double dipping is making a claim against both policies for the same thing. The same principle applies to claiming against Medicare and then making a claim for the same treatment against one’s health insurance provider.
How do I do that?
As I understand the system:
I can only claim for Medicare what is on the scheduled of approved services. If it’s on the schedule it is either not eligible for a private claim or one can only claim the gap or part there of. The insurer knows this and is unlikely to pay in full. They will as I understand make a claim on Medicare if you are claiming from them in full. This will trigger an exception if one has also been paid out by Medicare and prevent a double payment. Vice versa if Medicare reimburse the insurer for the scheduled fee on your behalf preventing Medicare making a subsequent identical reimbursement to the patient directly. Computer software bugs excepted.
You can’t, which is the point I have been making. If one claims against Medicare it can’t be then claimed against a health insurance as the Medicare schedule rate has already been paid. There are some which might he consider exceptions where some health insurance provide gap cover for specific items above the scheduled rate, such as you found for Bupa, this this isn’t standard across the industry for most scheduled items.
We have veered off track in relation to the original OP.
As I stated above, for scans it is so that there isn’t any double dipped and to place downward pressure on scan costs. It is worth noting that not all scans are covered by Medicare (those which sit outside the item coverages), and as such, won’t also be covered by a health insurance policy as indicated on the Government’s health website.
Edit: while one might disagree, Medicare and the private health insurance system in Australia has been set up to prevent double dipping. Medicare and health insurance cover is mutually exclusive, with no overlap in cover.
A State Government can make a form of double dipping claim for a patient. The public health system in a State receives funding to look after public patients from the Medicare Levy.
What sometimes happens is that a patient attends a public facility and are requested/required to complete a Medicare assignment. This should mean that the patient is no longer a public patient and has the choice of Doctor they wish to see, instead they are treated as a public patient and are seen by any Doctor who is available. The only time that the assignment has to be disregarded by the hospital is when a patient is seen by a “Resident” rather than a Registrar (often a Registrar will not be used for billing as well) or Specialist. If the resident or registrar consults the Specialist about the patient then the billing is submitted as if the patient has been attended by the Specialist.
So something as a brief somewhere around a 2 minute interaction by the resident with the specialist is treated as a complete appointment treated by the Specialist. So if a standard appointment (15 minute consult) would be paid by Medicare to the hospital/clinic as a full 15 minute specialist item. If a long appointment (30 minute), this would be paid as if the specialist saw the patient for the entire 30 minutes, regardless of actual time spent. So a public patient’s consult would be “double dipped” off Medicare. I guess this could be further impacted by any entitlement to Private Health Care rebates if someone was able to claim on the item number or numbers used.
[Reply to Mark M above - not sure how to tag in these threads]
Yes, thanks. I have one of those cards, but I suspect that the doctor I saw (not my usual one at that practice) did not know and/or was not particularly interested in finding me the cheapest scan, just the closest. I will be giving the GP practice feedback about that though.
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[To Phil T]
Yes, and I suppose in the best of all possible worlds I should have asked and phoned around before - which I will do next time, before being stung for over $100! I did not know there was a tick box for bulk-billing on the referral form, so didn’t even look for it - but will certainly ask next time.
They bulk-bill me at the GP practice because I have a Comm Seniors Health Card, so you’d think they could tick the box (if it exists on the form I had).
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Healthscope are pulling out of contracts with a lot of Health Insurers as Healthscope want to charge a number of patients extra for staying in one of their hospitals. BUPA and others had no fee contracts but Healthscope wanted to charge $100 for the overnight services and $50 for 1/2 day procedures.
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Healthscope tried the same thing with HCF two years ago. An agreement was reached.
Looks like another try on by this US style private hospital chain.
