After meeting with your specialist, you will have a plan for next steps. Your specialist may refer you onto another provider for preventative measures such as physical therapy or they may begin the process of admitting you to hospital for surgery.

Prior to being admitted, it’s best to discuss with Frank what information you will need from your specialist in order to work out your out of pocket expenses.

What to ask your specialist

In addition to any questions you may have about your condition, treatment and upcoming hospital stay, other things to ask your specialist may include:

  • Can you provide me with all of the relevant Medicare Benefits Schedule (MBS) item numbers for the procedure I am having?
  • Will I have to pay a gap between your fee and the amount I’m covered for under my health insurance? Can you provide me with a written estimate of this?
  • Will there be charges from other specialists involved in my treatment? How can I get an estimate of these?

Costs with care and how to understand them

As well as considering your care or a procedure, out of pocket costs associated with care should be confirmed. To stop any bill shock, talk to your specialist about costs and fees.

How to check your out of pocket costs before seeing a specialist

  1. Check your level of cover with Frank to make sure hospital stay and surgery are covered.
  2. Check the Government’s out of pocket guide to find what providers charge for the service.
  3. Talk to your doctor about costs and see if they have any recommendations for specialists within your budget.

Questions to ask your specialist

Will you be charging me an out of pocket expense?

There’s a limit to what Frank and Medicare will pay towards a doctors’ bills, but there's no limit to what a doctor can charge.

This means your doctor can choose to charge more than you’re covered for. To avoid any surprises, check with them to see if there will be any out of pocket expenses.

All of Frank's hospital covers come with Gap Cover. If your doctor, specialist, surgeon or anaesthetist charges more than the Medicare Benefits Schedule, Frank will cover you for up to 20% above the MBS (so you get up to 120% of the MBS).

What are the Medicare Benefits Schedule (MBS) item numbers for my procedure?

The Medicare Benefits Schedule (MBS) item numbers references a Medicare service and the amount subsidised by the Australian Government. These item numbers are helpful to have when you contact Frank as we use them to make sure that your procedure is included in your level of cover and to estimate any benefits payable to you.

Will there be any other doctors billing me?

Any doctors that are involved in your hospital stay will bill for their costs separately to your specialist. Other doctors may include the anaesthetist, pathologist, radiologist or an assistant in your operation.

These doctors may also bill us directly if they are registered for simplified billing but pathology and radiology fees will not receive the additional benefit. These doctors may charge an out of pocket expense, please check directly with them what these costs may be.

Informed financial consent

Your specialist should provide you with an estimate of fees prior to any hospital admission. This is known as Informed Financial Consent.

Your estimate will include details of any out of pocket or ‘gap’ you may have. A Medical Gap is the difference between what your doctor charges and what’s covered by Medicare and your hospital insurance cover.

Like many service providers, you are entitled to ‘ring around’ a number of providers for a quote or to discuss methods of care. You can also ask for background information, like how often they do the procedure you are having, and their complication rates, such as the proportion of their patients undergoing that procedure who go on to develop an infection.

Hospital fees and charges

Once your medical specialist has advised you which hospital they wish to admit you to, you should contact the hospital to confirm the costs of your care. Informed financial consent is about understanding any hospital costs before your admission (sometimes in an emergency this may not be possible). This should include information about any potential gaps including radiology and pathology services.

If you have chosen to have an excess on your hospital cover, you will need to pay this to the hospital, usually before your admission. You should also confirm whether there are any costs associated with accessing a private room, if this is relevant for your hospital stay.

Care in a private hospital

Frank Health Insurance has agreements with a large number of private hospitals in Australia. We recommend you check our participating hospital list to confirm that Frank has an agreement in place with the hospital where your medical specialist wishes to admit you.

For an admission to a contracted hospital, Frank can pay benefits that cover:

  • Hospital accommodation and meals
  • Nursing
  • Intensive care and operating theatre fees
  • Government listed surgically implanted prostheses, eg for a hip or knee replacement

If the hospital does not have a contract with Frank, we recommend you contact us as while benefits will still be paid up to a default rate, you are likely to have a significant gap to pay.

Some hospitals charge for things that health funds do not pay for, such as phone, wifi and television. Make sure you understand what you will need to pay the hospital if you are going to use these services.

More information about medical (doctor’s) bills

In Australia, medical services provided by doctors have a Medicare Benefits Schedule (MBS) fee, set by the Government. This is called the scheduled fee.

Medical services provided out of hospital

Private health insurers are not permitted to pay any benefits for medical services provided out of hospital (ie any services other than those provided while you are an admitted hospital inpatient). Medicare pays 100% of the scheduled fee for GPs and 85% of the schedules fee for specialists. If the doctor chooses to bill above the scheduled fee, you will have to pay the difference.

Next: Step 7 - What to expect