Fighting the gap: helping you reduce your out-of-pocket costs
You’re in a health fund, you go to hospital for a medical procedure and you end up tens of thousands out-of-pocket.
It’s a growing problem that many Australians are facing.
While health funds have been criticised for not covering the gap, this criticism is misguided.
Four Corners has backed this sentiment in their recent investigation into out-of-pocket expenses. Reviewing the medical bills of over 700 Australians, the program highlighted three key issues which affect the likelihood of out-of-pocket expenses occurring – bill creep, hidden fees and lack of regulation into what surgeons can charge.
You can read more about the Four Corners investigation here.
So, why are there out-of-pocket costs?
It comes down to the fact that doctors set their own fees; there is no requirement under law for doctors to charge regulated fees.
So, when you go to hospital, the cost of your medical procedure is set in accordance with the Medicare Benefits Schedule (MBS). Together with Medicare, Teachers Health covers you for the MBS fee.
But when your doctor charges more than the MBS fee, you pay the difference. That difference is your out-of-pocket costs, or ‘gap’.
Helping Teachers Health members reduce the gap
While we may not have the power to regulate what doctors charge, we have the tools and resources to help members reduce or eliminate out-of-pocket costs.
Access Gap Cover
Access Gap Cover is a billing scheme that allows Teachers Health to pay benefits above the set MBS fee for your medical procedures in hospital (up to certain limits).
In return, doctors who choose to participate in the scheme agree to charge you a lower fee. The charge will be higher than the set MBS fee, but probably less than they would’ve charged you otherwise.
Health provider search
You can search for providers who have participated in Access Gap by using Healthshare – a free, online medical directory which, as a member of Teachers Health, you have access to. Your GP can also access this information to guide their selection of specialists for referrals.
Find out how a specialist has previously charged patients (no gap, a gap of up to $400 or a gap of over $400). If your specialist decides to charge a gap, you can question why they are or you can ask your GP to refer you to someone else.
Want to try it out? Click here to access Healthshare.
Ask questions, and lots of them!
It’s important to talk to your doctor about their fees before you receive treatment. Ask them if they’ll participate in Teachers Health Access Gap Cover, query anything you don’t understand, and make sure they provide you with a written estimate of fees for the cost of all services. If they’ve charged at no gap 80 percent of the time, why can’t you be charged the same?
In the last financial year, over 95% of medical services paid by Teachers Health were charged under Access Gap Cover, so there’s a good chance your specialist will too.
If not, remember that you’re free to find another doctor who will. Ask your GP about alternative specialists and their charges, and seek a second opinion. It’s your right.
We’re here to help
If you have any questions, we’re here to help. You can contact our team on 1300 727 538 or email firstname.lastname@example.org.