Insurers: Transparency key to addressing out-of-pocket costs

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Transparency is the solution to patients facing high out-of-pocket costs, according to the private health insurance industry.

The industry's leaders have responded to reports in News Corp publications showing some specialists charging 10-times more than the Medicare fee.

The report was based on a copy of the AMA's unpublished 'List of Services and Fees'. News Corp created an online tool enabling consumers to compare the difference between the official Medicare fee and AMA recommended fee.

In its Private Health Insurance Report Card 2018, the AMA argues publication of doctors' fees as "impractical, and potentially unhelpful."

It says a single specialist could use a large number of item numbers in their practice, meaning a doctor's website could contain thousands of figures for the procedures they provide, once the number of different health funds and their variable benefit levels are taken into account.

"Also, simply publishing one fee for a particular treatment or procedure may mislead consumers, as it ignores clinical factors like the complexity of the procedure for that patient, who may have other health issues," it says.

The organisation says transparency in fees is ultimately a matter between medical specialists and individual patients.

Responding to the News Corp revelations, Private Healthcare Australia’s CEO Dr Rachel David said the majority of specialists try to do the right things by their patients but she has advised consumers to ask for quotes up front in advance of surgery.

Dr David said most specialists are aware that patients are in a vulnerable position when discussing the potential costs of treatment, but there are exceptions.

“Many patients are able to have their treatment with no gap or a known gap, but it pays to be prepared well in advance of surgery,” she said, recommending people speak to their GP and health fund about potentially finding a low-charging, no-gap or known-gap specialist.

In circumstances where patients may have had complications related to surgery or their bill contains unexplained charges, Dr David said patients should not pay before receiving an explanation.

“Importantly patients should be aware that there is absolutely no correlation between higher priced surgery and quality.

“Health funds do their best to cover the gap for most surgical procedures, but they are unable to chase fees which continue to escalate above inflation, without causing premiums to go up for everyone. Transparency around fees and charges is critical for the sustainability of the private health system, which provides over two-thirds of elective surgery in Australia,” added Dr David.

The managing director of Bupa Health Insurance, Dr Dwayne Crombie, described unexpected out-of-pocket costs as the number one concern of the company's customers.

"While the majority of doctors are doing the right thing, patients should know when a fee is higher than usual and be able to question why that is so," he said. "Any out of pocket costs, such as doctors' fees or hospital fees, must be known in advance. This is a critical component of informed financial consent."