Your medical bills

Understand your hospital, doctors' and extras bills as you may be entitled to claim a benefit from MBF.

Your hospital bills as a private patient

Typically, you will sign a completed claims form as well as pay for any excess, co-payment, or out-of-pocket expenses when leaving the hospital.

In most instances, the hospital will automatically send your hospital bill to MBF for payment. A benefit statement is sent to you typically within 2-4 weeks of your discharge date as confirmation of payment.

Your doctors' bills

The Commonwealth Government sets the amount they will reimburse for doctors' charges and pays Medicare benefits accordingly. This is known as the Medicare Benefits Schedule Fee ('MBS'). For eligible in-patient services, Medicare pays for 75% of the MBS; MBF pays the remaining 25%.

If a doctor charges you above what Medicare and MBF pays for these services, this creates a 'gap'. This relates to fees you are charged for services you receive from doctors (e.g. surgeon, assistant surgeon, anesthetist, radiologist, pathologist) while you are admitted to hospital, even if you do not see them personally.

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 are invited to participate in the MBF Medical Gap Scheme. Those who participate in this scheme and agree to treat you as a 'no-gap' patient for your inpatient treatment have agreed to accept the MBF benefit as full payment for your treatment. Therefore, if you are treated by one of these doctors, MBF will be invoiced directly by the doctor(s).

If your doctor(s) does not participate in the MBF Medical Gap Scheme for your private in-hospital treatment, you will be invoiced directly by your doctor(s) and you may have out-of-pocket expenses for your treatment. When you receive a bill from your doctor(s), you have two choices:

• You can pay the bill in full, and then visit a Medicare office to lodge your claim. You will need to obtain and complete a Medicare two-way claims form. This form covers any claim from Medicare and/or MBF. Medicare will forward the necessary paperwork to MBF.

MBF will then issue you a benefit cheque, or you can choose to have the benefit directly credited to your nominated bank, building society or credit union account via MBF Direct Credit.

OR

• You can take or post the unpaid bill to Medicare. You will also need to obtain and complete a Medicare two-way claims form. Medicare will forward the necessary paperwork to MBF for settlement.

MBF will return a benefit cheque made payable to your doctor either directly to you or to the doctor. If you receive the benefit cheque, you need to forward it to the doctor. Either way, you will be required to make any gap payment directly to your doctor.

You can access a Medicare two-way claim form from your nearest Medicare office or by visiting the Medicare Australia web site.

Remember to take the invoices and/or receipts along with your Medicare card with you when you go to the Medicare office.

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Your extras bills

MBF members can make extras claims in three ways - either by MBF AutoClaim, online or manually. Regardless of the payment method, any benefits you receive from extras healthcare providers are subject to the limits and waiting periods of your cover. You will be responsible for paying any extras 'gap' at the time of the service. Please remember you can only claim for extra services provided by an MBF Recognised Provider.

MBF Australia Limited
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If you have paid the account, MBF will issue you a cheque, or you can choose to have the benefit directly credited to your nominated bank, building society or credit union account via MBF Direct Credit.

If you have not yet paid the account, MBF will return a benefit cheque made payable to your provider either directly to you or to the provider. If you receive the benefit cheque, you need to forward it the provider. Either way, you will be responsible for any extras 'gap' payable to your provider.

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Additional information

• Gap and informed financial consent

  What are 'gaps' and what can you do about reducing them? What is informed financial consent?

• Understanding 'pre-existing' ailments

  Need answers on whether or not pre-existing ailments may affect your hospital benefits? Find information from the Private Health Insurance Ombudsman and MBF here.

• Insure, not sure - PHIAC booklet [PDF, 296k]

  Making decisions regarding your health insurance needs? This booklet has been prepared by the Private Health Insurance Council (PHIAC) to assist you and explain the Australian health system in simple terms.

• Waiting periods - PHIO brochure [PDF, 2.54M]

  Are you confused about waiting periods? This brochure is written by the Private Health Insurance Ombusdman to explain waiting periods that apply to private health insurance in Australia.

• Australian Government information

  For information on finding a Medicare Office, access to Medicare forms and information, visit the Medicare Australia web site.

  The Private Health Insurance Ombudsman is an independent services for consumers with health insurance problems or enquiries.

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