Financial Consent
To do your operation Dr Cole will organise a team of three or four people:
Himself
An assistant surgeon or nurse practitioner assistant
An specialist cardiac or thoracic anaesthetist
If required, a perfusionist (a specialist doctor who runs the heart lung machine)
No Gap:
If the team is all doctors, then these doctors follow the financial arrangement that Dr Cole chooses to use. At this point in time, Dr Cole chooses a No Gap financial arrangement and deals with your health fund directly. Dr Cole will charge what your health fund will pay in a No Gap arrangement, and deal directly with the health fund, as do the team of doctors that is arranged for you. Practically speaking, this means you should not receive a bill or a gap from Dr Cole or from any of these doctors, as all invoices will be submitted directly to your health fund.
The costs that cannot be controlled by Dr Cole are the costs of the Intensive Care Unit, Radiology and Pathology. You may get bills from these services, but in general, these are small amounts. Note that if large numbers of tests are required, the costs can add up to large amounts.
Other medical specialists may be asked to consult during your care. They will individually have separate financial arrangements with you.
Estimating No Gap Medical Fees:
To estimate what fees your health fund will be paying on your behalf, there are several steps. The first is to identify how your operation matches with the lists of procedures in the Medical Benefits Schedule. The Medicare Benefits Schedule lists suggested total fees to be charged for medical services, and the amount that the Federal Government will contribute for specific services. It is available online and searchable here. A list of common item numbers can be found here. The Federal Government covers 75% of the suggested fee, and your health fund covers the remaining 25%. In a No Gap arrangement your health fund will then pay an additional amount to your doctors, which varies from fund to fund, but is around 50% of the MBS fee. This total amount (150% of the MBS fee) will then be paid to the doctors involved in a No Gap arrangement.
How fees are set:
The amounts of the fees set in the Medicare Benefits Schedule were set at its development in the 1970’s and 1980’s, and since being set, have at times increased with inflation, whilst for other time periods, indexation has been frozen. A separate schedule of fees with suggested amounts for procedures is published by the Australian Medical Association. These fees would typically result in a gap payment as they are typically higher amounts than the MBS schedule and the no gap supplement from health funds. Individual prices can be set separately to both of these schedules. An example of how the fees vary is here.
Fees and Value:
The fee paid for a service and the value you receive from the service are different considerations. Dr Cole seeks to minimise the stress for you and your family during this time, and hence choses to use the no gap arrangements, rather than use the AMA schedule or individually set fees that would result in you paying an out of pocket gap. The aim is to not add financial stress to the stress of surgery. Whether the price of service matches the value you receive is part of what you are considering. Alternative financial arrangements can be made if you do not feel the no gap arrangement through your health fund represents the value you receive.
Specialist Nurse Practitioner Assistant:
Currently health funds do not compensate Specialist Nurse Practitioner Assistants. If there is no doctor available to assist Dr Cole, then he may arrange for a Specialist Nurse Practitioner Assistant. These are nurses who have undertaken specialty training and further degrees to train in order to assist surgeons in theatre. Some have specific skills for assisting in cardiac surgery in particular. If they are arranged for your operation, then they will invoice you directly for their assistance. Fees are generally between $300 and $500.
Consent:
To participate in the No Gap arrangements and deal directly with your health fund, the health funds require that you indicate you have consented to this arrangement. Please complete the form below to indicate that you understand the financial arrangements available and to which arrangement you agree.
Version Date 27 April 2020