Why do Gap Payment exist in Private insurance Surgery??

The Role of the Doctor, the Insurer and Medicare!!!!!!!!

One of the most important components of hospital insurance is the cover for medical services expenses during hospital treatment.The cover provided by different funds delivers different outcomes for patients. There is essentially 3 types of Billing structure from your service Provider (Usually specialist in-hospital stay) Note- Health insurance does not cover outpatient service e.g. consult, bloods, x rays etc etc
1. Medicare only. - this usually applies to the public hospital and is usually used as an item number guide in the private sector
2. No Gap/Known Gap- This usually applies to a specialist who has signed up with the health funds and will only charge a designated scheduled fee for a procedure. The Gap is set by your health fund and the specialist has to abide by this schedule
3. AMA or Surgeon Preferred Fee- Australian Medical Association (AMA) publishes a schedule of fees for all items on the medicare Benefit Schedule (Govt codes for all surgeries and procedures) . This is set according to CPI indexation and cost of services provided. If your Doctor chooses to charge this fee or higher than your health fund may only pay up to medicare schedule fee only- leaving the patints significantly out of pocket (GAP)

There a few health funds that will pay the full AMA fee therefore significantly limiting your GAP fees. Usually there premium will be slightly higher.
The questions you need to ask is
1. Do you want to pay low premium and pay an 'Excess" later (GAP)

If you want to have a Comprehensive cover ask your insurer if they cover up to AMA schedule of fee and compare the premiums and then make the decision.

Below is a poster published by AMA outlining why the GAP is increasing. The Healthfunds base there schedule of fees on the MBS (Gov schedule)
Happy to answer questions on PM if required.

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