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Going to Hospital – Costs and Informed Consent
Navy Health understands that going to hospital can be a stressful experience for our members in itself, without having to understand the intricacies of the medical system such as fees and charges, out of pocket expenses, your rights as a patient, the process and the jargon. This post aims to break down some of the complexities associated with going to hospital and provide you with “must do’s” that may assist in reducing your out of pocket expenses.
When you go to hospital, there are 2 costs that generally will be charged, Hospital and Medical. The hospital charges are generally for your accommodation, theatre fees etc. and the medical charges are direct from your treating practitioner i.e. specialist/surgeon/anaesthetist etc.
Hospital and medical claims are claimable through an eligible hospital policy with Navy Health.
What will Navy Health pay for?
As a private health insurer, Navy Health is bound by legislation on how much we can pay and the medical procedures/services that we can pay on. Navy Health will only pay for medical procedures that your hospital policy covers that have a Medicare Benefit Schedule item number assigned.
Navy Health can only pay for inpatient procedures – which means we can only pay for procedures where you have been admitted into a hospital. We cannot pay for consultations with your specialist or emergency department admissions (in a private hospital).
When you are admitted into hospital, as an in-patient, Navy Health will ensure that 100% of the expenses occurred while you are in hospital are covered. These expenses include things such as your overnight bed fees, theatre fees, prosthesis charges and drugs prescribed for your inpatient stay.
Navy Health cannot guarantee 100% coverage in the following scenarios:
|•||The private hospital is not a contracted facility with Navy Health;|
|•||You have been admitted for a service that your Navy Health policy does not cover or is restricted;|
|•||You are within your policy wait periods and/or your condition has been deemed a pre-existing condition by Navy Health’s independent medical examiner|
|•||Where your practitioner has utilised a prosthesis that is not on the Australian Government Prosthesis list; and|
|•||Where your practitioner has prescribed a drug that is not on the Pharmaceutical Benefits Scheme.|
In most cases, the hospital will send the bill directly to Navy Health to pay directly. Should your hospital send the bill to you, please contact Navy Health.
Please note, if you have an excess amount on your policy, you will be required to pay that at the hospital.
Medical costs are those that are charged by your treating practitioner (doctor, anaesthetist, surgeon etc.). These are billed separately to the hospital charges and the cost is shared between Navy Health and Medicare and potentially yourself.
Navy Health will pay 25% of the fee set for the service by Medicare (provided you are covered for the procedure) and Medicare will pay the remaining 75% of the fee they have set.
Many practitioners charge above and beyond the fee set by Medicare and this is where you will incur an out of pocket expense.
What are out of pocket expenses?
The out of pocket expense, or ‘gap’, is the amount of money that you will be required to pay as a result of your medical practitioner charging above the set (or scheduled) Medicare Service fee for your treatment.
By law, Navy Health is only able to pay a maximum of 25% of the scheduled fee for in-patient services, with Medicare paying the remaining 75%.
Practitioners are within their rights to charge greater amounts than the allocated Medicare scheduled fee for your service and it is important you ask your practitioner their costs before agreeing to a procedure.
How can you reduce/manage your out of pocket expenses?
The best way Navy Health members can reduce or get rid of out of pocket expenses all together is through the Navy Health Access Gap Scheme. Under this scheme, Navy Health will pay a higher amount to your practitioner, if they agree to charge a no-gap or known gap fee to you.
No Gap means that Navy Health will cover the gap in its entirety, should your practitioner participate.
Known Gap means that you will have a maximum out of pocket expense no greater than $400, except obstetrics where your out of pocket will be no greater than $800.
For more information on the Navy Health Access Gap Scheme, click here.
If your practitioner does not or does not want to participate in the scheme, you are within your rights to look for a practitioner that does – you can do so by searching in HealthShare.
HealthShare, is an easy to use tool that not only allows Navy Health members to search for providers that participate in the Navy Health Access Scheme but also allows you to research practitioners, search facilities and understand how often your chosen practitioner participates in the Navy Health Access Gap Scheme.
What is informed financial consent?
Before you receive treatment you are entitled to ask Navy Health and your practitioner about how much your procedure will be and what your out of pocket expenses will be.
Navy Health recommends that you take the following steps:
Talk to your practitioner and ask for;
|1.||A breakdown of all the Medicare Benefit Schedule item numbers they will use in procedure; and|
|2.||A breakdown on the total costs (including their costs) for each of the item numbers;|
|3.||Ask if they participate in the Navy Health Access Gap Scheme;|
|4.||Ask them to provide you with a written quote.|
Call Navy Health on 1300 306 289 or check www.navyhealth.com.au to check:
|1.||Your Navy Health policy covers you for your procedure;|
|2.||If you have any excess that you will have to pay; and|
|3.||The facility you are going to is a contracted facility through Navy Health – Facility Search|
If, after your procedure, you receive an unexpected bill or the amounts are higher than you were quoted, you are within your rights to question the practitioner and ask why you were not informed of these costs. If you are unsatisfied with the response, please contact Navy Health and we can assist you with the next steps.
Case study – it always pays to ask
Chris, a Navy Health member was booked in for a Colonoscopy and a Gastroscopy. Chris called Navy Health to seek advice on what he needed to do for his admission and a Member Services Consultant stepped him through questions to ask his specialist.
“I’m so glad Navy Health advised me about the access gap. When I spoke with the doc, he advised me that he would gladly participate in the No Gap scheme. Because of this, I saved $550 and had no out of pockets cost at all.”
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