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.