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Why do I have to pay a gap when being treated in hospital?

2 minute read
Person paying the 'gap' using eftpos after their hospital treatment

If you’ve ever been stung with higher than expected fees for a private hospital visit, you might’ve been told that it’s because your doctor’s fees are higher than the fee in the Medicare Benefits Schedule (or MBS), which is set by the Government.

But, if you’re confused by the acronyms and want to know how to avoid paying out-of-pocket costs, we’ve put together a simple guide to answer your biggest questions.

What’s the MBS and how does it affect me?

Medicare gives Aussie residents (as well as certain visitors to Australia) access to medical and public hospital services. This is managed by the Department of Human Services.

The MBS is the list of all the services that Medicare subsidises and what it deems as an ‘appropriate fee’ for each service (for the complete list, you can download the Medicare Benefits Schedule Book).

So, why do I have to pay extra?

The reason is because your treating doctor might decide to charge more than what the Medical Services Advisory Committee has deemed an ‘appropriate fee’ in the MBS.

Your doctor can do this on a case-by-case basis and for a number of reasons, including their geographic location, their reputation or individual patient circumstances.

How can my private health insurance help?

If you need to go to hospital, nib offers a MediGap scheme which is designed to cover the costs of medical fees for in-patient services. This scheme is an agreement we’ve made with a network of doctors and specialists who may elect to charge the MediGap fee for your procedure and bill us directly.

If your doctor chooses to participate in the MediGap scheme for your treatment, you won’t have to pay anything extra for their fees. It’s important to check with your treating doctor well in advance if they will charge the MediGap fee for your procedure.

If you are going to hospital, make sure you check out nib’s Going to Hospital page. This page gives you information on health insurance, tips on how to eliminate out-of-pockets and some helpful questions to ask your specialist.

To find out the details of your current policy, log onto nib’s Online Services.

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