How to choose a specialist

If the hospital treatment you're planning is marked as 'covered' or 'restricted' on your Hospital Product Sheet you can choose your specialist. This means you can:

• pick someone you like and trust
• be proactive about controlling your costs.

Here we focus on the cost part, and how to get the most value from your Teachers Health Hospital cover.

The Medicare Benefits Schedule (MBS) is a detailed list of fees the government has set for medical services, including specialist treatment. Each item on the list has a unique code (or item number).

When you meet with a specialist, ask for the item number(s) that’ll figure in your treatment, then call us on 1300 727 538 to check you're covered for them.

In the private system, specialists can set their own fees, and some charge a lot more than others. So be sure to ask these questions too:

• How much do you charge for this treatment?
• Is your charge more than the MBS fee? If so, how much more?
• Will there be any other specialists involved in my care? (If so, the above questions apply to them too).

This info is important, because when you use your Hospital cover:

• Medicare pays 75% of the MBS fee
• We pay 25% of the MBS fee.

If a specialist charges more than the MBS fee, the Medicare and Teachers Health contributions won’t cover the full amount. The extra cost is known as ‘the gap’.

Unsurprisingly, most people aren’t happy about the prospect of out-of-pocket costs, especially the eye-watering kind. If this includes you, it’s time to talk about the Access Gap Cover scheme.

If you're quoted more than the MBS fee (which isn't unusual) ask the specialist if they'll treat you under Access Gap.

If they agree, you pay either no gap at all, or a known gap which is capped at $500 per doctor per hospital episode ($800 for obstetrics).

If they won't treat you under Access Gap – and they're not obliged to – you can look for another specialist who might. One of the key perks of private Hospital cover is choice – if shopping around could save you money then go ahead.

Many people feel awkward talking about money, but please do it upfront so you know where you stand. No one wants to be reeling from bill shock when they should be focusing on getting better.

Whatever your situation, ask the specialist for a written estimate of all the costs. Understanding and agreeing to their estimate is an essential part of giving Informed Financial Consent.

This isn't the time to hold back – ask your specialist (or one of their team) about anything that doesn't make sense.

We know this one can be confusing. If you have any questions about using your Hospital cover, please give us a call on 1300 727 538 so we can help.