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

2 minute read
young male patient in hospital talking to a nurse about whether his procedure is covered

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.

Can I choose which hospital I go to?

To minimise the out-of-pocket expenses our members could incur when visiting a hospital, we have agreements with most Australian private hospitals. These agreements mean we can reduce or eliminate out-of-pocket expenses for our members when they need hospital treatment. Use our online hospital search tool to find private hospitals we have agreements with.

If you're an nib member heading to hospital soon, make sure you check out our Going to Hospital page. This tool gives you information on health insurance, tips on how to reduce any out-of-pocket expenses and helpful questions to ask your specialist. To find out the details of your current policy, chat to someone about your upcoming hospital visit or get some guidance, call us on 13 16 42.

Person paying the 'gap' using eftpos after their hospital treatment

How else can I reduce my out of pocket expenses?

  • Check you have the right level of cover to suit your needs - you can compare and change your cover in Online Services
  • Always call nib before going to hospital
  • Choose a specialist registered with nib MediGap and ask if they’ll participate for you
  • Ask for written confirmation of fees from your doctors and the hospital prior to your admission
  • Ask your specialist about all of the potential costs that may be involved in your procedure – including how to understand the fees of other specialists involved
  • Check if there are alternative options which could cost you less

Depending on your level of cover, you might have to pay an excess for your hospital stay when you’re admitted. This is paid directly to the hospital and is separate to your potential out of pocket expenses.

To find out the details of your current policy, login to Online Services or contact our award-winning member service team on 13 16 42.

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