NewsHow to close the gap on pesky health insurance gap payments

How to close the gap on pesky health insurance gap payments

If you fear some of the intricacies of navigating private health insurance, like being stung financially, here's a straightforward fix which could save you hundreds.

When the doctor or specialist's office sends you a letter with the operation's item numbers, so you can check with your fund that you are covered, try just one thing.

Don't be shy, don't wait to be asked and don't hesitate: merely ask to be part of the "gap access scheme". You don't have to know what it means or does, and it may come with a slightly different name, but you do have to request it to get it.

This simple advice from Zachary at my health fund call centre I reckon might have saved me up to a thousand dollars on a recent procedure* in the private hospital system.

Naturally, I'd called to check my hospital cover was sufficient, and there were no nasty surprises. I knew there'd be a $700 excess for the one night stay as I'd chosen that option to keep the premium low.

I was prepared after being stung by a surgeon whose nominal adherence to a previous fund's gap scheme shaved a mere $500 off a $4,500 out-of-pocket charge. I pushed, but that's all I got.

The dreaded gap payment is one of the unpredictable tyrannies of the system and is responsible for no end of strife amongst consumers.

In short, when you are a private patient in a hospital, Medicare pays 75% of the Medicare Benefits Schedule fee for each item. If you are covered by your fund, another issue some discover too late, it will pay the other 25%.

But doctors and others are free to charge more, sometimes much more than the MBS fee, and you pick up the difference which can be sizeable.

One saving grace is that funds have gap scheme arrangements with some doctors/surgeons to limit the hit but usually only if you request its use.

My small fund, for example, says it has an arrangement with the Australian Health Service Alliance to give its members access to what they call Access Gap Cover.

It's a billing system which pays the specialists who are registered to use it more than the MBS fee in exchange for limiting any of out-of-pockets to the member.

Great idea, but again you have to ask. I requested inclusion in the scheme in an email to the surgeon, and when I called the anaesthetist's office. There was no push back or questions.

As a result, when the surgeon's bill came ahead of the operation, the gap fee was $500, a sum which - while a sting to many - was far less than I feared.

I reckoned the anaesthetist's gap would be a similar figure and was pleasantly surprised when the bill arrived. What was described as a 'co-pay' stood at $286.

They are unwelcome extras but for various reasons part of the system. Until broader reforms can be made the best move to look after your interests is to ask your fund about their gap scheme and then ask your doctor's office to be included.


*For those curious my condition was neither rare nor painful but necessary. My slight bump in the groin was finally diagnosed as a double inguinal hernia. I was repaired in a standard keyhole surgical procedure involving mesh. So far, so good but no exercise for four weeks.

Any information is general advice, it does not take into account your individual circumstances, objectives, financial situation or needs.


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Doris from VIC commented:

who is paying for this 

Anonymous from VIC commented:

thank you very much for the information 

Anonymous from NSW commented:

Thankyou for that info 

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