Bupa has rejected as 'scaremongering' claims changes it has announced to its Medical Gap Scheme amount to the introduction of US-style managed care.
Australia's largest private health insurer recently announced changes to its Medical Gap Scheme and policies that provide 'minimum benefits'.
Changes to the Managed Gap Scheme mean it will no longer apply to the four per cent of private hospital beds not contracted by Bupa.
The change will require doctors to inform a patient if they are going to be treated in a contracted hospital and what out-of-pocket medical costs they will face.
"Unfortunately, and in all too many cases, customers have not been told when being booked into a hospital or day facility that it's not contracted with Bupa," said the insurer in a statement.
"When this is combined with ad hoc use of the medical gap scheme by treating doctors, customers have been left with large out-of-pocket costs which they weren't expecting."
The insurer issued a clarification yesterday, confirming people who want to be treated by specialists who work in public hospitals can still use the Medical Gap Scheme for elective, pre-booked procedures.
"This is as long as the hospital follows the same process as the private system, and that they don’t charge anything extra for hospital costs, like accommodation or theatre fees," it said.
Bupa rejected any suggestion the change signalled the introduction of US-style managed care.
"The direct answer is absolutely not," it said. "Australia does not require customers or doctors to seek pre-approval prior to treatment. This continues to be the case today.
"Doctors, never health insurers, will always determine patients’ treatment and care options as they do today; nothing has changed."
In an interview, AMA president Dr Michael Gannon played down any concern with gap payments.
"Nearly 90 per cent of operations are provided by doctors at no-gap; another five or six per cent at known gap of less than $500.
"We don't think we're the problem, but when we see unilateral action like we've seen in the last week from big insurers like Bupa to say what they won't be covering, we encourage individual policyholders to ring up, ask, and make sure they're covered if and when they get sick."
Bupa said some doctors have reacted negatively to the changes because it means out-of-pocket costs will become "very obvious."
"It also means if they choose to send you to a non-contracted facility, potentially one they have an interest in, customers will be aware of the additional charges they will be faced with, as a result of the doctor’s decision.
"Currently doctors are able to charge patients whatever they want to, and may charge different customers different fees for the same thing.
"Bupa believes greater transparency is required, and these changes support that."
The insurer also announced changes to policies based on 'minimum benefits'.
According to Bupa, around 35 per cent of its customers have ‘minimum benefits’ as part of their policy, meaning they are heavily restricted.
The insurer said, as a result of feedback from customers, it is converting ‘minimum benefits’ to exclusions and redistributing the money into a lower premium increase and additional benefits such as introducing gap free dental care on a number of common preventative services at selected dentists.
It confirmed the change does not include services for psychiatric, rehabilitation and palliative care which will still be covered at the minimum benefit (Restricted Cover) level on some products.