The Australian Government sets a Medicare Benefits Schedule (MBS) fee for most medical services. The MBS fee is used to work out how much Medicare will pay. Each procedure involved in your treatment will have a MBS “item number” and there is normally a MBS fee for each item number. Medicare pays a benefit of 75% of the MBS fee for in-hospital treatment and 85% of the MBS fee for out-of-hospital services. MBS fees are not the fees doctors charge, they are set by the government to manage the benefits paid by Medicare.
Consultation Fee Policy
The Medicare Rebate for an outpatient service is 85% of the MBS schedule fee. The “gap” between the amount charged and this 85% rebate is not covered by your private health insurance for outpatient services and therefore a financial obligation on yourself arises, and you will face an “out –of-pocket” charge. As a patient you pay 15% of the MBS fee, plus any amount charged by the doctor over the MBS fee. Private health insurers are not allowed to provide cover for doctors’ fees for out-of-hospital services. The Australian Medical Association (AMA) recognises that Medicare benefits levels are fixed arbitrarily by the federal government and that benefit levels have not kept pace with inflation, the escalating costs of running a practice and increasing medical indemnity premiums, thereby widening the gap between reasonable fees and Medicare benefits. The fees charged by Miss Jane O’Brien have been determined after careful study and investigation of practice costs and other relevant and material circumstances, and are considered as being fair, reasonable and appropriate for the services provided.
Why is there a Gap?
a) AWE = average weekly earnings CPI = consumer price index
b) Medicare Benefits
The graph above clearly highlights why the gap between reasonable fees based on the costs of running a practice and the Medicare reimbursement has widened.
If your consultation is prolonged, an additional charge at a pro-rata rate will be incurred. An additional charge will be made for any diagnostic services or procedures (eg ultrasound scan or needle biopsy) performed during your consultation. A full price list is available upon request. Other x-rays and pathology tests, if required, will be performed by other independent practices and you will be charged separately by them for those services. Cancellations on the day of appointment may incur a cancellation fee.
Epworth Breast Service has a policy of informed financial consent and should you subsequently be booked for an operation you will be provided with a written quote prior to any procedure if there is likely to be an out-of-pocket expense.
Operation Fee Policy
The Schedule Fee / Medicare Rebate for an operation covers the normal aftercare customarily provided, as well as the operation itself. The aftercare period is the duration of the normal healing process. “Aftercare” includes attendances in hospital and post-operative consultations after discharge. (an additional charge may be made for attendances or services that do not form part of “normal” aftercare).
As the post-operative consultation following breast surgery for discussion of pathology results, especially for breast cancer, can be quite involved and often prolonged, the operation fee itself charged by this practice is higher than for some other forms of surgery eg hernia repair, to allow for this.
The Australian Medical Association (AMA) recognises that Medicare benefits levels are fixed arbitrarily by the federal government and that benefit levels have not kept pace with inflation, the costs of running a practice and medical indemnity, thereby widening the gap between reasonable fees and Medicare benefits.
The AMA therefore produces a yearly list of medical services and fees to provide guidance to its members when determining their own schedule of fees. The amounts have been calculated by the AMA after careful study and investigation of practice costs and other relevant and material circumstances, and are considered as being fair, reasonable and appropriate for the services provided. This practice uses the AMA “List of Medical Services and Fees” as a guide to determining operation fees.
Informed Financial Consent
A financial obligation on yourself (as the patient) will arise when the fee charged for the service is more than the combined (Medicare and private fund) benefits payable. We charge fees considered fair and reasonable by the AMA and as these fees are usually higher than the MBS (Medicare Benefits Schedule) fees, you will usually face out-of-pocket charges after receiving Medicare and private health fund benefits.
We have a policy of informed financial consent and you will be provided with a written quote prior to any operative procedure if there is likely to be an out-of-pocket expense. This is an estimate only, and may change if additional or different procedures are required. This quote covers the surgical service only and does not cover services provided by other doctors such as anaesthetists, assistant surgeons, radiologists, nuclear medicine physicians or pathologists, or other costs associated with your stay in the hospital or the day surgery unit, such as accommodation or pharmacy. Our quote is for the total cost of our surgical fee.
Doctors can advise the overall fee, but health funds need to advise the rebate that will be paid. Health funds have a central role in ensuring their members have access to timely information about the rebates they’re entitled to, about any copayment expected in the event the hospital is not in contract with the fund, and about any excesses the patients have agreed to pay. (Some patients who are under the impression that they have full private health insurance, find that they have signed up for very basic policies which do not provide them with sufficient cover to have their treatment within the private sector).
Private health insurance arrangements are complex and depend on individual patients’ circumstances/policies. The private fund rebate you receive will vary depending on your insurance company and your individual policy. It is therefore strongly advised that you obtain from your insurer details of your personal rebate entitlement to enable you to calculate your out-of-pocket expense.