Medical Costs Finder disclaimer
This tool is a general guide to the costs of specialist services. It shows general information on typical costs, it cannot be used to determine a person’s actual costs.
To determine your individual cost, you must talk to your health providers (for example, your doctor, specialist or hospital) about their fees and your health insurer about your policy coverage before you agree to treatment.
This disclaimer is for the Medical Costs Finder. It is in addition to our broader site disclaimer.
Medical Costs Finder data sources
The Medical Costs Finder uses data from the most recently publicly available financial year as stated on the results page.
The data used in this tool relies on data that may not be complete and, where appropriate, the data has been rounded to present whole numbers.
Data for hospital services
The Medical Costs Finder presents in-hospital results based on Hospital Casemix Protocol (HCP1) data we collect from private health insurers. Insurers receive HCP1 data from declared hospitals following a private admitted episode of hospital treatment.
The HCP1 data used in the Medical Costs Finder reflects:
- fees charged for treatments provided in private hospitals to patients with private health insurance
- what Medicare and insurers paid for these services
Data for out of hospital services
The Medical Costs Finder presents results for the cost of out of hospital treatments, these are services that do not involve a hospital admission.
Each service is allocated a Medicare Benefits Schedule (MBS) item number and medical specialty as part of the MBS data collected by Services Australia (Medicare). This allows information to be presented showing which specialties use each item and the associated typical costs.
The focus of the Medical Costs Finder is medical specialists' costs. However, the MBS items may also be used by other health providers such as GPs, dentists or pathologists. The results presented includes details of all providers unless otherwise specified.
The following MBS items has been excluded and are not included in results:
- items that are solely used by GPs, or other allied health professionals
- ‘hospital admitted only’ items
- pathology items (99% of out of hospital pathology is bulk billed)
We also publish other Medicare statistics on a quarterly and annual basis.
Medicare Safety Nets and Multiple Services Rules
The ‘Government pays’ amount shown in MBS item costs details is the usual basic Medicare payment for patients not admitted to hospital. Sometimes the actual Medicare benefit is different to the usual basic benefit amount due to Medicare Safety Nets or the Multiple Services Rules.
If the patient is eligible for the Medicare Safety Nets, the amount paid by Government will be higher for that patient.
When more than 1 MBS item is provided at the same time, the Medicare benefit may be lower than usual due to the multiple operation rule (MOR). Medicare benefits affected by the MOR were not excluded from the overall dataset.
A lower Medicare benefit for additional items reflects the efficiencies to the provider when multiple services are performed at the same time.
The median patient payment shown on the tool for out of hospital services takes into account all benefits paid across the year, excluding Medicare Safety Nets benefits.
Terms we use
For the Medical Costs Finder, we simplified the description for some of the MBS items. These abbreviated descriptions provide you with an easier to understand description of the treatment. The full description of each MBS item can be found at MBS Online by searching for the MBS item number.
The Medical Costs Finder also refers to ‘clinical categories’. Clinical categories were created as part of the recent private health insurance reforms and are hospital treatments described in a standard way that allow for the grouping of medical services.
Geographical data presentation
The Medical Costs Finder uses the Department of Health and Aged Care’s database of declared hospitals to determine the location of a hospital.
The tool can provide results locally, by state or territory, or nationally.
When you search the tool, it collates data from all relevant admissions. However, it will only show you a result if there is enough combined available data to ensure a person, hospital or provider cannot be identified.
The smallest region the tool can display results for is a Primary Health Network (PHN). The tool uses PHNs to identify geographic areas smaller than a state other than for Tasmania, the Northern Territory and the Australian Capital Territory which are categorised as a single PHN.
If the tool can’t show you a result for a PHN because those results might make it possible to identify a person, hospital or provider, it will show you results for the state or across all of Australia instead.
We refer to hospital admissions in this disclaimer and in the Medical Costs Finder to help explain the results.
To do this the tool uses data related to what’s called a ‘hospital separation’.
A hospital separation occurs when:
- a patient leaves the hospital, or
- a patient stays in hospital but their admission status changes – for example, they were admitted to hospital as an acute surgical patient but stay in hospital and become a rehabilitation patient
Effectively, the tool treats each hospital separation as a distinct admission even if the patient doesn’t actually leave the hospital and enter again.
The tool will show you fees, Medicare and insurance payments, and out of pocket costs for hospital admissions where any gap was paid for the admission as a whole. This includes costs for all MBS subsidised medical services provided by a doctor or other health provider during the admission. Health providers could include surgeons, assistant surgeons and anaesthetists. Medical services could include diagnostic imaging and pathology.
For example, a patient is admitted for surgical grommet insertion. The MBS item for grommet insertion is 41632 and it incurs an out of pocket cost of $425. The patient also has anaesthesia (MBS items 17610, 20120 and 23031), which costs a total of $210 out of pocket. The tool will therefore show a total medical out of pocket cost of $635 for this admission.
Hospital admissions in the data for each of the included services are those where any of a set of identified MBS items was the main or principal item for the admission. Hospitals identify a main or principal item for each admission as part of the HCP1 dataset. The tool will show you the MBS items used to identify relevant admissions for the procedure you have searched.
The tool doesn’t show what patients paid for hospital charges such as accommodation or theatre costs, or the cost of medical devices. However, idoes show how much insurers typically paid for these costs.
In most cases we apply further criteria before including an admission in the dataset to make the results more useful. For example, we exclude admissions that last longer than is considered typical for a particular course of treatment.
Pregnancy and birth
The admitting hospital allocates a Diagnostic Related Grouping, or DRG, to every admission.
The HCP1 data we are sent identifies both:
- the main MBS treatment item for each admission
- the admission’s DRG
The DRG assigned to pregnancy and birth procedures tells us the kind of delivery and how complicated it was. We use it to divide admissions for pregnancy and birth procedures into:
- caesarean sections and vaginal deliveries
- minor or moderately complex procedures and very complex procedures
Although you might not know what kind of delivery you will have, presenting the results like this can help you understand the costs associated with different kinds of deliveries.