How to avoid unexpected doctors’ costs

Updated July 2024 | 5 min read  
Expert contributor Dr Andrew Cottrill, chief medical director of HCF  
Words by Angela Tufvesson 

Out-of-pocket expenses or a 'gap payment' can come as a shock after a hospital stay. Here’s how your hospital cover can help reduce the amount you’ll need to pay. 

Having a medical procedure in hospital can be stressful. You’re probably focused on what the treatment involves, how best to prepare and how long you’ll stay. Then there’s organising logistics at home or work.

But it’s also important to be fully informed about the costs of your procedure before you get to hospital to avoid a nasty shock when bills arrive. Medical bills can add up, especially if you’re hit with costs you weren’t expecting.

HCF’s chief medical officer Dr Andrew Cottrill recommends doing your research and getting involved in the decision-making surrounding your care. “You'll end up finding a doctor who’s more suited to your needs and minimising your out-of-pocket expenses,” he says.

Here’s how to reduce and avoid unexpected costs from doctors and specialists.

Understanding your level of cover

Before your procedure, it’s important to understand the full benefits of your hospital cover as well as your extras cover, and what services they cover. This includes knowing your annual limits (the amount you can claim on any one service), any pre-existing conditions and waiting periods (how long you need to wait before you can make specific claims) and which providers you should use.

Hospital cover aims to reduce the cost of being treated in hospital. Depending on your policy, this may include being able to claim your doctor’s fees, the cost of the stay, the operating costs and some medicine while you’re admitted, as well as emergency ambulance charges.

Extras cover helps reduce out-of-pocket expenses associated with the day-to-day costs of managing your health for services like dental, optical, hearing, physio, chiro and podiatry. You could get 100% back on a range of no-gap services through our More for You^* programs with our nationwide network of participating providers. To make an appointment at a provider close to you, use our Find a Provider tool.

What are out of pocket expenses?

In Australia, the government sets a fee for most medical services in the Medicare Benefits Schedule (MBS). When you have treatment in a private hospital, Medicare covers 75% of the MBS fee, and your private hospital insurance pays the other 25% (provided you’re covered for the service).

However, doctors are free to decide what to charge for their services (these are known as ‘medical costs’) and many choose to charge more than the MBS fee for various reasons. This means after Medicare and your health fund contribute, there might still be a difference that you need to pay.

This is often called the ‘out-of-pocket’ or ‘gap’ payment and you’re more likely to incur out-of-pocket expenses for fees for specialists and anaesthetists. If you’re claiming for the first time in a calendar year, you may also need to pay an excess. This will depend on the excess option you chose when you signed up to the policy.

Finding out the cost of your procedure

It’s your right to get an estimate of all the likely costs related to your procedure before you have treatment to help you understand what you might have to pay. Being aware of all the costs, understanding and agreeing to them is known as informed financial consent.

Dr Cottrill says it’s common to feel uncomfortable talking to your doctor about what they charge. “We appreciate that asking about fees and charges can be difficult, but it’s your right to be fully informed,” he says.

Ask your doctor or specialist for a written quote with a breakdown of the costs (the more complex your procedure, the more detailed this may be). Make sure it includes costs for things like diagnostic tests, medications and booking fees.

Ask for the Medicare item number(s) too – this is the unique code Medicare assigns to each procedure (or part of a procedure) and items like prostheses. Your doctor’s practice staff may be able to tell you what the Medicare rebate is for each part of your procedure, otherwise you can find out from the government’s online Medical Costs Finder.

Also ask for details of any other doctors likely to be involved in your treatment (for example, an anaesthetist or assistant surgeon) so you can get information about their fees and charges, too.

You’ll also need to find out about the hospital charges, as they’re billed separately from your doctors’ costs. Your hospital bill will cover things like your accommodation, operating theatre and other elements of your inpatient care.

Next, check with your health insurer whether your hospital cover will cover the procedure and if you’ll need to pay an excess or any gap costs, and for which services. It's also worth checking whether you have any waiting period to serve like the waiting period for pre-existing conditions.

Our Preparing for Hospital cost indicator tool gives you an idea of the typical costs of some of the most common hospital procedures. You can see the average total costs and out-of-pocket costs incurred by HCF members, as well as how your choice of doctor and hospital affect that average cost.

If you’re not happy with your diagnosis, HCF will connect you to a network of independent, Australia-based medical specialists for a free second opinion^{^}. You’ll have the chance to ask questions so you can confidently make the best decision for your health and your treatment.

How to avoid or reduce your gap payment

For HCF members, the best way to ensure you have no, or lower, out-of-pocket expenses is to choose a doctor who participates in our Medicover scheme.

We have arrangements with specialists across Australia who provide more than 95% of their services with no gap payment (that is, no out-of-pocket expenses) or a ‘known gap’ payment (which is capped at $500)⁺. Doctors who participate in Medicover bill us directly, so you don’t have to worry about managing the bills.

It’s important to ask your doctor if they’ll participate in our Medicover scheme. If they don’t, and they’re unwilling to, you can look for a doctor who does. “You can exercise your right to go to the specialist of your choice, but you must ask the doctor whether they will participate in Medicover,” Dr Cottrill says.

Finding a participating specialist in our Medicover scheme is easy using our Find a Provider search tool. You can search by type of specialist and preferred hospital or location and get information about doctors’ biographies, locations and contact details.

Find a Provider also shows you how often specialists participate in Medicover⁺, as well as the out-of-pocket expenses members have experienced with that provider for a particular procedure. “This will give you an idea of the pattern of out-of-pocket expenses for each provider,” Dr Cottrill says.

Members can also avoid out-of-pocket expenses on their hospital bills by choosing one of the many private hospitals we have an arrangement with (known as participating hospitals). “We cover over three-quarters of private hospitals [in Australia],” Dr Cottrill says.

If you’re treated at a participating hospital, there will be reduced costs for services covered under your policy (such as any applicable excess or co-payment). 

Ask your doctor to participate

HCF member, 30-year-old William, was shocked when he received higher-than-expected invoices in the mail before his nasal septum repair.

“I’ve had limited experience using my private hospital cover and was so confused by the fees and charges I actually considered not going through with the surgery,” he says.

“I called HCF and the consultant was really helpful. He explained that the hospital I was booked in for was one of HCF’s participating hospitals. My procedure was covered under my hospital insurance but I’d still have to pay the excess. He answered my questions, explained it all clearly, and encouraged me to call the surgeon’s rooms and ask whether he’d participate in HCF’s Medicover scheme. I figured it was worth a shot.”

William’s surgeon agreed to participate, which saved him more than $2,000.

Received an unexpected bill?

If you’ve had a procedure and received a bill that you didn’t expect, or that was higher than you were quoted, Dr Cottrill advises not to just pay it. “Contact the doctor’s office and ask what the charges are for and why you weren’t informed,” he recommends.

If you’re an HCF member and aren’t satisfied with their response, contact us and we can either advocate on your behalf or recommend you contact the Australian Government’s Private Health Insurance Ombudsman.

Questions to ask your doctor

Having an in-hospital procedure is a big deal – so it’s important to do your research. Ask questions and get all the information you need to avoid unexpected bills and financial stress.

Ask your specialist or their practice staff these questions.

• Can I have a written quote with a breakdown of your fees for the procedure/s, with Medicare item numbers?
• What will be the total cost of my treatment?
• Which other doctors (for example, an anaesthetist or assistant surgeon) will be involved in my procedure and what are their contact details? (You’ll need to contact each one to find out their fees and charges.)
• Are there any other charges, like outpatient consultations^#, technology fees or management or booking fees?
• Do you (or will you) participate in HCF’s No-Gap arrangement?
• If not, what will be the gap payment for me and for which services?
• Which hospitals can I have the procedure at to avoid out-of-pocket expenses?

When you have all this information, contact HCF to find out if your policy covers the procedures, whether there’ll be any excess payments, whether you have any waiting periods to serve and if the hospital is a participating hospital.

We can help you work out what your out-of-pocket expenses are likely to be and whether you can reduce them by choosing a specialist who participates in Medicover or a participating hospital.

Download our Gap Checklist.

Choosing cover that’s right for you

Find hospital cover that suits your needs with HCF's range of customisable hospital and extras covers. We're not your typical health fund – we genuinely want you to get great value cover. We gave more back to our members in benefits than the industry average for every dollar our members paid in premiums over the last 10 years^** ensuring they have quality cover when they need it with top hospital gap coverage and a comprehensive national network of specialists and extras providers.