Out-of-pocket expenses for private medical treatment (Informed Financial Consent)

This page contains information about how out-of-pocket expenses for private medical expenses can arise.

Page last updated: 10 October 2008

What is informed financial consent?

Informed financial consent (IFC) is the provision of cost information to patients, including notification of likely out-of-pocket expenses (gaps), by all relevant service providers, preferably in writing, prior to admission to hospital or treatment.

Doctors’ fees

The Government sets a fee for every medical service in the Medicare Benefits Schedule (MBS). When you have hospital treatment as a private patient, Medicare will pay 75% of the MBS fee. Your private health insurer will pay 25%.

Gaps for doctors’ fees come about when your specialist, and/or the other doctors involved in your hospital care, charge more than the MBS fee. Your insurer can pay more than 25% of the MBS fee, if the doctor is prepared to use its “gap cover arrangements”. In this circumstance, you will either have no gap to pay, or you will be informed in advance about any gap. Many doctors are prepared to use gap cover arrangements.

Doctors can choose, on a case-by-case basis, whether they wish to use an insurer’s gap cover arrangements. If you doctor chooses not to use your insurer’s gap cover arrangements, you would be required to pay the gap between the MBS fee and the total charge out of your own pocket.

How can I find out about any gaps before going to hospital?

Before going to hospital as a private patient, you should ask the doctor for an estimate of his/her fees. You should also ask about any other doctors likely to be involved in your care (eg anaesthetist, assistant surgeon) and how to get information about their fees.

Check with your health insurer about how much is likely to be covered by your health insurance policy.

You should also check with your hospital about any likely out-of-pocket costs relating to your hospital accommodation.

Useful information

  • The Private Health Insurance Ombudsman’s (PHIO) Out–of-Pocket Expenses information
http://www.privatehealth.gov.au/healthinsurance/howitworks/outofpocket.htm
  • The PHIO’s Facts and Advice on IFC – Your Right To Know
http://www.phio.org.au/facts-and-advice/informed-financial-consent.aspx
  • PHIO brochure about medical fees
http://www.phio.org.au/downloads/file/PublicationItems/DoctorsBill.pdf
  • IFC Fact Sheet
http://www.phio.org.au/downloads/file/factsandadvise/ifcfactsheet.pdf
  • IFC Checklist
http://www.phio.org.au/downloads/file/factsandadvise/ifcchecklist.pdf
  • IFC Consumer Surveys
2007 Informed Financial Consent Consumer Survey (PDF 874 KB)
2006 Informed Financial Concent Consumer Survey (PDF 432 KB)
2004 Informed Financial Consent Consumer Survey (PDF 788 KB)

Where do I make a complaint?

Sometimes a doctor may be prepared to negotiate fees and/or terms, so if a bill is causing you distress we encourage you to contact the doctor’s office in the first instance.

If you would like to pursue your complaint, we suggest that you contact the:
Private Health Insurance Ombudsman (PHIO)
http://www.phio.org.au/
Complaints Hotline - freecall 1800 640 695, or
Informed Financial Consent Hotline - 1800 700 465.

PHIO brochure on making a complaint: http://www.phio.org.au/downloads/file/PublicationItems/MakingAComplaint.pdf

If you are having difficulty downloading the PDF documents, please email mbd.web@health.gov.au and we will arrange for an alternative format or a copy to be sent to you.