SW Cancer Services

Insurance and Billing

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Introduction

Cancer treatment can be expensive, both because of the nature of the treatment and because the treatment may need to be given over a long period of time. Treatment may also be delivered by many health professionals including several different medical specialists e.g. an oncologist and a radiotherapist.

In addition you may need to visit a hospital for regular treatment.  This treatment is generally done during a same day visit, however there could be times when you need to stay overnight.

In Australia, whenever you have medical treatment (in or out of hospital) you can nominate to be treated as either a “public” patient or a “private” patient. Public patients have their treatment paid for by Medicare whereas private patients may use a combination of Medicare and a private health insurer (“health fund”). The nature of the care given and the standard of the care given to patients does not differ, the difference is about choice and the amount of freedom you have to choose. For example only a privately insured patient can choose their own doctor when they are hospitalised.

There is also a difference in costs.

It is important to know that all patients, regardless of whether they nominate to be treated as a public or a private patient, may have to pay a “gap”. A gap is the amount of money that is the difference between what the doctor charges the patient and what Medicare/private health insurers reimburse the patient. These payments may also be called “out of pocket” expenses, “co-payments” or the “excess”, because the patient has to pay this amount.

Paying for diagnostic tests, doctors’ fees, medical treatment and hospitalisation can be confusing.  Not all privately insured patients will be billed the same or be reimbursed the same because there are many different insurers (“health funds”) and they all offer different levels of cover.  You should always contact your private health insurer to check your level of cover.

It is important to have some understanding and expectation of the bills you will receive, which ones to send to Medicare and which ones to send to your health insurer (if you have one). You should take the time to read the information below about giving informed financial consent. If you are unsure or confused you should contact your Doctor’s office, private health insurer, Medicare or seek assistance from someone familiar with the system.

The following information is a summary from the Medicare website. For more information visit www.medicareaustralia.gov.au or phone Medicare on 132 011.

Medicare

Medicare is Australia’s universal health care system. Medicare ensures that all Australians have access to free or low-cost medical, optometric and hospital care while being free to choose private health services and in certain circumstances allied health services. 

Who is eligible for Medicare?

People who reside in Australia are eligible if they hold Australian citizenship, have been issued with a permanent visa or hold New Zealand citizenship. Other people may be eligible for Medicare.

Visit http://www.medicareaustralia.gov.au/public/migrants/index.jsp

What does Medicare cover?

The benefits you receive from Medicare are based on a Schedule of Fees (also called the Medical Benefits Schedule – MBS) set by the Australian Government. Doctors may choose to charge more than the schedule fee.

Medicare provides benefits for costs incurred both as an out patient (not hospitalised) and for in-hospital services.

Out-of-hospital services

In relation to treatment for cancer, Medicare provides benefits for:

  • consultation fees for doctors, including specialists
  • tests and examinations by doctors needed to treat illnesses, including X-rays and pathology tests
  • most surgical and other therapeutic procedures performed by doctors
  • specified items for allied health services as part of the Chronic Disease Management program.

You can choose the doctor who treats you for out-of-hospital services. For more information on what fees Medicare cover, visit www.medicareaustralia.gov.au

In-hospital services

If you choose to be admitted as a public (Medicare) patient in a public hospital, you will receive treatment by doctors and specialists nominated by the hospital. You will not be charged for care and treatment, or after-care by the treating doctor.

If you are a private patient in a public or private hospital, you will have a choice of doctor to treat you. Medicare will pay 75 per cent of the Medicare Schedule fee for services and procedures provided by the treating doctor. If you have private health insurance some or all of the outstanding balance can be covered. You will also be charged for hospital accommodation and items such as theatre fees and medicines. These costs can also be covered by private health insurance.

What’s not covered by Medicare?

In relation to treatment for cancer, Medicare does not cover such things as:

  • private patient hospital costs (for example, theatre fees or accommodation)
  • ambulance services
  • home nursing
  • physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology (except specified items introduced for allied health services as part of the Chronic Disease Management (CDM) program)
  • acupuncture (unless part of a doctor’s consultation)
  • the cost of prostheses (except External Breast Prostheses covered by the External Breast Prostheses Reimbursement Program)
  • medicines (except for the subsidy on medicines covered by the Pharmaceutical Benefits Scheme)
  • medical and hospital costs incurred overseas
  • medical services which are not clinically necessary
  • surgery solely for cosmetic reasons

You can arrange private health insurance to cover many of these services.

How do I pay my doctor?

Bulk billing

Bulk billing is when your doctor bills Medicare directly, accepting the Medicare benefits as full payment for a service. This means if your doctor bulk bills, you cannot be charged a booking fee, administration fee, a charge for bandages, record keeping or a charge by your doctor’s company.

Many doctors bulk bill some of their patients such as pensioners or health care cardholders. If your doctor bulk bills you will be asked to sign a completed form after the service and will be given a copy.

There are circumstances where more than one service can be provided at the same visit and your doctor is not required to bulk bill each service.

Accounts

If your doctor charges you a fee, you can:

  • pay the account and then claim the benefit from Medicare or
  • claim your unpaid account from Medicare and receive a cheque made out in the doctor’s name which you give to your doctor along with any outstanding balance

Medicare usually pays:

  • the full Schedule fee for GP services
  • 85 per cent of the Schedule fee for other out-of-hospital services
  • 75 per cent of the Schedule fee for in-hospital services

The Schedule fee is a fee for service set by the Australian Government and not what your doctor charges you.

Financial Safety Nets

Medicare Safety Net

The Medicare Safety Net provides families and individuals with financial assistance for high out-of-pocket costs for out-of-hospital Medicare Benefits Schedule (MBS) services. Once you meet a Medicare Safety Net threshold, you may be eligible for additional Medicare benefits for out-of-hospital MBS services for the rest of the calendar year. Also available is the PBS Safety Net if you and your family need a lot of medicines in any year.

The difference between the doctor’s fee and the Medicare rebate is the patient’s out-of-pocket cost. Once a patient’s out-of-pocket expenses for medical services reaches the safety net threshold of $413.50 (as at 1 January 2012), all future Medicare services are paid at 100% of the Medicare Benefits Scheduled fee (not at the 85% Medicare rebate) for the remainder of the calendar year for all Medicare cardholders. For example:

Before Safety Net Threshold Doctor’s Fee MBS Rebate(at 85% Scheduled Fee) Out-of-Pocket Cost
Initial specialist consult $124.00 $71.40  $52.60
After Safety Net Threshold Doctor’s Fee MBS Rebate(at 100% Scheduled Fee) Out-of-Pocket Cost
Initial specialist consult $124.00 $83.95 $40.05

The threshold is indexed annually from 1 January and operates on a calendar year, 1 January to 31 December.

Make sure you are registered and your information is up to date with Medicare Australia.

Extended Medicare Safety Net

The Extended Medicare Safety Net (EMSN) provides a further rebate on top of the Medicare Safety Net for Australian families and singles that incur high out-of-pocket cost for out-of-hospital services.

The difference between the doctor’s charge and the Medicare rebate is the patient’s out-of-pocket cost.

The EMSN provides 80% of any further out-of-pocket expenses for out-of-hospital costs in a calendar year, once the relevant thresholds have been met. For concession cardholders and families eligible for Family Tax Benefit A the threshold is $598.80 (as at 1 January 2012). For all other Medicare cardholders the threshold is $1,198.00 (as at 1 January 2012). For example:

EMSN Threshold Met Doctor’s Fee MBS Rebate(at 100% Scheduled Fee *) Out-of-Pocket Cost before EMSN Rebate EMSN Rebate (80%) Out-of-Pocket Cost
Initial specialist consult $124.00 $83.95 $40.05 $32.04 $8.01

* The Medicare benefit is paid at 100% of the Scheduled fee because the Medicare Safety Net threshold has been reached.
Eligibility for the threshold lapses on 31 December each year and must be re-established from January 1 each year.

Upper limits apply to the amount of EMSN payable for:

  • assisted reproductive technology (ART) services (MBS items 13200-13209 and 13212-13251);
  • two services for injections of poly-L-lactic acid (Sculptra) for the treatment of facial lipoatrophy (MBS items 14201 and 14202);
  • obstetric services (MBS items 16400-16609, 16618 and 16624-16636);
  • two services relating to video conferencing for ART and selected obstetric services (MBS items 13210 and 16399);
  • three types of varicose vein surgery (MBS item 32500, 32520 and 32522);
  • one type of cataract surgery (MBS item 42702);
  • hair transplantation for the treatment of hair loss as the result of disease or injury (MBS item 45560); and
  • some pregnancy related ultrasounds (MBS items 55700-55730 and 55762-55775).

Medical Expenses Tax Deduction

Patients may be eligible to claim a tax offset of 20% of their total out-of-pocket medical expenses provided that the total out-of-pocket costs reaches the threshold of more than $2,060 for 2011-12 financial year. There is no upper limit on the amount you can claim.

The total out-of-pocket medical expenses are the eligible medical costs the patient has paid less any rebates received, or entitled to receive, from Medicare or a private health insurer.

Not all medical expenses qualify to be included in the out-of-pocket medical expenses calculation. A complete list of what medical costs qualifies for the tax offset can be obtained from the Australian Taxation Office (ATO). To see whether you are eligible to receive the tax offset benefit we recommend you contact the ATO or your accountant.

For more detailed information on Medicare call 132 011 or visit www.medicareaustralia.gov.au

Private Health Insurance

Although Medicare provides universal health insurance you can choose to take out private health insurance to give you more health options and to cover items that aren’t covered by Medicare.

Below is a side by side summary of what is covered by private health insurance and what Medicare covers for hospital, medical services and general treatment, pharmaceutical benefits and ambulance.

Since 2007 funds have also been able to cover a variety of alternatives to hospital treatment, known as Broader Health Cover.

Hospital

Private Cover

Medicare

You can choose to be treated as a private patient in either a public OR a private hospital.  You can choose your own doctor, and decide whether you will go to a public or a private hospital that your doctor attends.  You may also have more choice as to when you are admitted to hospital.  If you choose to be treated as a private patient in a hospital (public or private), Medicare will cover you for 75% of the Medicare Benefits Schedule (MBS) fee for associated medical costs.The remaining hospital and medical costs will be charged to you – some or all of these costs may be covered on your private health insurance, depending on your policy.  The remaining costs include 25% of the MBS fee for doctors’ services and any amount the doctors charge above the MBS fee, plus some or all the costs of:

  • hospital accommodation,
  • theatre fees,
  • intensive care,
  • drugs, dressings and other consumables,
  • prostheses (surgically implanted),
  • diagnostic tests,
  • pharmaceuticals, and
  • any additional doctor’s fees.

 

You can be treated as a public patient in a public hospital by a doctor appointed by the hospital.  You cannot choose your own doctor and you may not have a choice about when you are admitted to hospital.  You can choose to be treated as a public patient even if you are privately insured.As a public patient you will be treated at no charge. Medicare does not cover:

  • private patient hospital costs (for example, theatre fees or accommodation),
  • medical and hospital costs incurred overseas,
  • medical services which are not clinically necessary, or surgery solely for cosmetic reasons.

 

Medical Services and General Treatment

Private Cover

Medicare

If you visit a doctor outside a hospital, Medicare will reimburse 100% of the MBS fee for a general practitioner and 85% of the MBS fee for a specialist – this applies whether or not you hold private health insurance. If your doctor bills Medicare directly (bulk billing), you will not have to pay anything.
Medicare does not provide benefits for the following:

  • most dental examinations and treatment,
  • most physiotherapy, occupational therapy, speech therapy, eye therapy, chiropractic services, podiatry or psychology services,
  • acupuncture (unless part of a doctor’s consultation),
  • glasses and contact lenses,
  • hearing aids and other appliances,
  • home nursing.

You can arrange private health insurance to cover many of these services.

Medicare provides benefits for:

  • consultation fees for doctors, including specialists,
  • tests and examinations by doctors needed to treat illnesses, such as x-rays and pathology tests,
  • eye tests performed by optometrists,
  • most surgical and other therapeutic procedures performed by doctors,
  • some surgical procedures performed by approved dentists,
  • specific items under the Cleft Lip and Palate Scheme,
  • specific items under the Chronic Disease Management (CDM) Program.

Pharmaceutical

Private Cover

Medicare

Under the Pharmaceutical Benefits Scheme (PBS), you pay only part of the cost of most prescription medicines purchased at pharmacies – this applies whether or not you hold private health insurance. The rest of the cost is covered by the PBS. You must present your Medicare card to obtain this benefit. The amount you pay varies with the medicine, up to a standard maximum. People with concession cards have a lower maximum payment.
You can arrange private health insurance to cover many prescription medicines which aren’t listed on the PBS. Most funds will require you to make a co-payment towards the cost and will have limits on how much you can claim. Some prescription medicines are not listed on the PBS. You pay the full amount for these non-PBS items.

For more detailed information visit www.privatehealth.gov.au

For a list of providers of private health insurance visit www.privatehealth.gov.au/dynamic/healthfundlist.aspx

If you wish to compare health insurance providers visit www.privatehealth.gov.au/dynamic/compare.aspx or www.iselect.com.au

 

 

“Gap” Payments

A ‘gap’ is the amount you pay either for medical or hospital charges, over and above what you get back from Medicare or your private health insurer. It may also be referred to as a “co-payment” or an “out-of-pocket” expense or an “excess”. Some health funds have gap cover arrangements to insure against some or all of these additional payments.

Before you go to hospital, you should ask your doctor for an estimate of their costs, if there will other doctors involved in your care (e.g. anaesthetist, assistant surgeon) and what their charges will be. You should also check with your health fund to find out exactly how much is covered with your policy.

Hospital gaps

Many hospitals have arrangements with health funds to fully or partially cover costs relating to hospital accommodation. If you go to a hospital that does not have an agreement with your health fund, you may face significant out-of-pocket expenses for your treatment.

If your health insurance policy has an excess or co-payment, you will have to pay the agreed amount of excess or co-payment towards the cost of hospital treatment out of your own pocket, even if your hospital has an agreement with your fund.

Medical gaps

Some health funds have gap cover doctors agreements made with particular doctors that may cover all or some of the doctors’ fees for your hospital treatment. If your fund does not have an agreement with your doctor you may have to contribute towards the doctor’s bill out of your own pocket.

The Government does not set doctors’ fees and the doctor is free to decide on a case-by-case basis whether he or she wishes to use an insurer’s gap cover arrangement.

For more detailed information, contact the Private Health Insurance Ombudsman on 1800 640 695 or visit www.phio.org.au

Informed Financial Consent

Before you receive your treatment you are entitled to ask your doctor, your health fund, and your hospital about any extra money you may have to pay out of your own pocket, commonly known as a ‘gap’ payment. Knowing how much your treatment will cost is called Informed Financial Consent.

  • Ask your treating doctor or specialist wherever practical how much their fee will be, and if you will need to pay a gap. For major treatment this information should preferably be provided in writing.

You may have more than one doctor involved in your treatment, for example, a surgeon and anaesthetist. Your surgeon should be able to advise who else will be treating you and how you can contact the other doctors to seek fee information from them.

You may have lower or no out-of-pocket medical costs if your treating doctors elect to use your health fund’s gap scheme. You are entitled to ask your doctors if they will use your fund’s gap scheme.

  • Ask your health fund whether your policy will cover the procedure, and whether you will need to pay an excess, co-payment or any other charge associated with the treatment. Your health fund may need you to obtain the Medicare item numbers your doctor will be using to give you an accurate quote. If you are within waiting periods, you will also need to ask your doctors to fill in medical certificates for assessment by the fund of whether benefits will be paid.
  • Ask the hospital whether they have an agreement with your private health fund and whether you will have to pay any gaps or extra costs. Your hospital should perform a membership eligibility check with your health fund before you are admitted and seek your informed consent to incurring any out-of-pocket costs associated with your admission. This information should preferably be provided in writing.

 

What can I do if my bill is much higher than I expected?

We suggest you first check whether you agreed to these charges at the time of your consultation.

For more detailed information contact the private Health Insurance Ombudsman or visit

www.phio.org.au/facts-and-advice/informed-financial-consent.aspx



Specific Providers

If you require specific information about the costs of a specific component of your treatment, you should contact the provider direct.

If you are receiving chemotherapy treatment in the Oncology Department at St John of God Hospital in Bunbury you may visit www.sjog.org.au/hospitals/bunbury/patients__visitors/accounts.aspx

or phone (08) 97221612

If you are receiving radiotherapy treatment at Genesis Cancercare in Bunbury you may visit www.genesiscare.com.au or phone (08) 9726 6400