Gap and informed consent
What are 'gaps' and what can you do about reducing them?
A 'gap' is the difference between what the hospital and/or your doctor or other healthcare professional charges, and the benefits paid by Medicare and MBF - in other words, how much you have to pay yourself.
The most common is the 'medical gap'. This relates to fees you are charged for services you receive from doctors (eg. surgeon, assistant surgeon, anaesthetist, radiologist, pathologist) while you are in hospital, even if you do not see them personally.
Remember, under current legislation, health funds cannot cover doctors' charges for out-of-hospital visits-for example a consultation in the doctor's room.
Medical gap, the Medicare Schedule of Fees and the MBF Medical Gap Cover Scheme
The Commonwealth Government sets the amount it will reimburse for doctors' charges for the purposes of paying Medicare benefits. This is known as the Medicare Benefits Schedule Fee ('MBS'). For eligible inpatient services, Medicare pays for 75% of the MBS. Above that, MBF pays the remaining 25%.
If a doctor charges you above the MBS, this creates a 'gap'. The law prevents MBF from paying any amount charged by your doctor above the MBS unless there is an agreement in place between your doctor and MBF or the doctor agrees to participate in MBF's Medical Gap Cover Scheme.
Doctors who participate in this scheme and agree to treat you as a 'no gap' patient have agreed to accept the MBF benefit as full payment for your treatment. Therefore, if you are treated by one of these doctors, there will be no 'medical gap' to pay for that doctor's charge.
There are more than 5,600 such 'no-gap' doctors nationally. However, as doctors are independent of MBF, we cannot guarantee a participating medical gap doctor in every area or that a participating doctor will treat every patient on a 'no gap' basis.
What is informed financial consent?
Ask your specialist to explain the costs of your hospital admission including any prostheses gap amount, their own fees, any fees that other doctors involved in the admission might charge, and any other expenses involved. If there are any gaps for you to pay, ask for a written cost estimate. This is known as 'informed financial consent'. Remember, this relates to fees you are charged for services you receive from doctors (eg. surgeon, assistant surgeon, anaesthetist, radiologist, pathologist) while you are in hospital, even if you do not see them personally.
Obtaining this information is extremely important before any planned hospital admission.
So, before going to hospital, always ask your specialist:
- to explain all the costs involved in your treatment (see above: 'Informed financial consent'); and
- whether he or she will participate in the MBF Medical Gap Cover Scheme for your treatment.
Also, please be aware that it is quite possible that not every doctor involved in your hospital treatment, e.g., anaesthetist, radiologist, pathologist, assistant surgeon, is a 'no-gap' doctor. So you may have to pay gaps for their services.
Find doctors who participate in MBF's Medical Gap Cover Scheme.