Health funds fighting an uphill battle against rising fees

You’re in a health fund, you go to hospital for a medical procedure and you end up tens of thousands out-of-pocket.

While health funds have been criticised for not paying up, this criticism is misguided.

Four Corners has backed this sentiment in their recent investigation into out-of-pocket expenses. Reviewing the medical bills of over 700 Australians, the program concluded that the finger of blame should be pointed elsewhere – surgeons who overcharge.

The investigation highlighted three key issues including bill creep, hidden fees and lack of regulation into what surgeons can charge.

Mr Brad Joyce, Chief Executive Officer of Nurses & Midwives Health, says that the fund is standing right beside it’s members in the fight against growing out-of-pocket costs.

“We’ve talked to members who are growing increasingly frustrated with their out-of-pocket charges, and rightly so”

“While we don’t have the power to regulate what surgeons charge, we believe that knowledge is power. At Nurses & Midwives Health, we’re committed to educating and informing our members so we can help to reduce or eliminate out-of-pocket costs”

“A range of resources and programs are available for our members, including Access Gap Cover and the HealthShare portal on the Nurses & Midwives Health website, which lists doctors who have participated in Access Gap Cover previously.”

“We also encourage our members to ask questions, it’s their right. Ask questions of their specialist, ask questions about their treatment and cost, ask their GP about alternate specialists and their charges, and ask the health fund about what they’re covered for,” Mr Joyce said.

Why out-of-pocket costs keep rising

Bill creep

One main issue found was bill creep, where a patient needs multiple procedures, tests and consultations for one ailment.

While the bills continue to pile up, many aren’t covered by your health fund because they’re considered outpatient services. By law, health funds are not allowed to pay for these services.

Hidden fees

Some of the medical bills received showed that patients had been charged a booking or administration fee, which is not only illegal, but highly unethical.

If you see a fee like this appearing on a statement, ask your doctor what it’s for and the relevance of it. If you don’t receive a reasonable answer, you’re within your rights to report it.

You can report your concerns to the Royal Australasian College of Surgeons professional.standards@surgeons.org

Overcharging – why it happens

The simple fact is that doctors can charge whatever they like – it’s in our constitution. The law forbids enforcing doctors to charge regulated fees.

For that reason, it’s almost impossible for health funds to set premiums to cover what doctors may charge – especially when these fees reach outrageous levels.

What you can do

  • Under Access Gap Cover, available through Nurses & Midwives Health, members can reduce – or eliminate – out-of-pocket expenses if their anaesthetist, surgeon or specialist agree to charge under a certain rate.
  • Access the HealthShare portal on the Nurses & Midwives Health website to find doctors who have participated in Access Gap Cover previously (Note: doctors can choose to participate in Access Gap Cover on a case-by-case basis, so previous participation is not a guarantee).
  • If a doctor chooses to participate (or not), they must provide a written estimate of fees for the cost of the services. This is known as Informed Financial Consent.
  • Talk to the doctor about their fees and query any items that you don’t understand.
  • Ask your GP about alternate specialists and their charges.
  • Seek a second opinion, it’s your right.

Additional resources