Fees, rebates and out-of-pocket costs

Why there is no price list on this page

It would be easy to publish a number and it would mislead most people who read it. What a consultation or a procedure costs depends on which Medicare item numbers apply, which is decided by what is actually done rather than what was planned, on the facility and on the level of private cover the person holds. Two patients having what sounds like the same colonoscopy on the same morning can end up paying very different amounts, and one of them may pay nothing.

So instead of a figure that would be wrong for most readers, what follows is how the billing is put together and what you are entitled to be told before you agree to anything.

What a consultation costs

A consultation is billed by the rooms as a single fee. Medicare pays a rebate against it, and the difference between the two is the out-of-pocket amount.

Three things change the fee:

• Whether it is a first appointment or a review. Initial consultations are longer and are billed under a different item number.
• Whether you have a current referral. A GP referral lasts twelve months and a specialist referral three months. Without a current referral you can still be seen, but no Medicare rebate is payable at all, which usually costs far more than the inconvenience of getting one.
• How long the appointment takes. Complex problems attract longer consultation items.

The rooms will tell you the fee and the expected rebate when you book. Ask at that point rather than on the day, because it is easier to plan around.

Why a procedure generates several bills

This is the part that catches people out. A colonoscopy or gastroscopy in a private facility is not one bill. It is usually three, sometimes four, from different people, arriving at different times.

• The proceduralist. The fee for performing the procedure itself
• The anaesthetist. Billed separately, by a different practice, and not set by the rooms
• The facility. The hospital or day surgery charges for the theatre, the nursing staff and the recovery bay. If you hold private cover this is usually the part your fund pays
• Pathology, if biopsies or polyps are taken and sent for examination. This one arrives weeks later, which is why it surprises people

Receiving four envelopes for one morning is normal and does not mean you have been billed twice. Each is for a different service.

Where the gap comes from

Medicare sets a schedule fee for every item number and pays a rebate based on it. Where a doctor's fee is higher than the schedule fee, the difference is the gap, and it is paid by the patient.

For the facility part, private health funds have agreements with hospitals and day surgeries. If you have appropriate cover and the facility has an agreement with your fund, that part is usually covered apart from any excess on your policy. Two things determine whether it is: the level of your cover, and whether the procedure is in a category your policy includes. Gastrointestinal endoscopy sits in a category that many mid-level policies cover and some basic ones do not.

Some doctors participate in a fund's gap cover scheme, which reduces or removes the out-of-pocket amount for their part. Whether that applies in a given case is a question worth asking directly.

What you are entitled to be told, and when

Informed financial consent means knowing what something will cost before it happens, not afterwards. It is not a courtesy. The Commonwealth Ombudsman's position is that patients are entitled to ask about any out-of-pocket amount before treatment, and the Australian Medical Association's guidance is that the estimate should be in writing and should come early enough to make a decision with.

In practice, before any procedure is booked you should have:

• The Medicare item numbers that are expected to apply
• The fee for each part, and the expected rebate against it
• The likely out-of-pocket amount, in writing
• The name of the facility, so you can check it against your fund
• A clear statement of what could change it. Usually that is finding something that needs removing, which adds an item number

If any of that has not been offered, ask for it. A practice that cannot produce a written estimate before a booked procedure is not meeting the standard.

The public option, and when it is the right one

A colonoscopy in a public hospital costs nothing. The trade-off is waiting time, and how long depends on the clinical urgency assigned to the referral rather than on when it arrived.

Urgency is not a judgement about the person. A positive bowel screening test, rectal bleeding or iron deficiency with no obvious cause all carry short target times in the public system, and a patient with any of those is generally seen quickly whether they go public or private. Surveillance after previous polyps, on the other hand, is not urgent by design, and that is where public waits are longest and where private is often chosen for timing rather than for anything clinical.

A referral can be made to either. It is a reasonable thing to ask about, and the answer depends on the reason for the test rather than on preference.

There is more on this on the colonoscopy page, and the bowel cancer screening page covers the free colonoscopy that follows a positive screening test.

If you do not have private cover

Two routes remain open. A procedure can be done in the public system at no cost, with the wait determined by clinical urgency as above. Or it can be done privately as a self-funded patient, where Medicare still pays its rebate for the doctors' fees but the facility charge is paid in full by you, which is the largest single component.

If you are considering taking out cover in order to have a procedure, note that most policies carry a general waiting period of two months and twelve months for a pre-existing condition, so it rarely solves an immediate problem. Ask the fund about waiting periods before assuming it will help.

Questions worth asking before you book

• What are the item numbers, and what is the fee for each part?
• What is the expected Medicare rebate, and what is the gap?
• Will the anaesthetist bill separately, and can I have their estimate too?
• Which facility will it be at, and does it have an agreement with my fund?
• Is there an excess on my policy, and has it been paid this year?
• What would change the cost on the day?
• When will the pathology bill arrive, if biopsies are taken?

None of these are awkward questions. They are the ones the rooms answer every day.

Where consultations and procedures take place

A/Prof Viraj Kariyawasam is a consultant gastroenterologist and hepatologist. Consultations are in Norwest, Rouse Hill, Pennant Hills and Macquarie Park.

Procedures are performed at Norwest Private Hospital, Macquarie University Hospital and Pennant Hills Day Surgery. A referral from your GP is needed for a consultation.