Financial Consent
Known Gap Arrangement
This document explains your financial obligations for the medical service(s) you are about to receive. Dr Cole seeks to minimise the stress for you and your family during this time, and hence chooses to use the Known Gap arrangements, rather than use the AMA schedule or individually set fees that would result in you paying a large out-of-pocket gap. The aim is to not add financial stress to the stress of surgery.
Dr Cole agrees to participate in your health fund’s Gap Cover Scheme. Under the Known Gap Arrangement, Dr Cole charges a fee that is partially covered by Medicare and your private health insurance. However, there is a known gap, which is a capped out-of-pocket cost that you will need to pay. By Dr Cole agreeing to the terms of the Gap Cover Scheme, this ensures that your procedure is eligible for the maximum benefit payable by your health fund and minimises your out-of-pocket expenses.
Cost Breakdown
1. Medicare Benefits Schedule (MBS) Fee
* Medicare will cover 75% of the MBS fee for in-hospital services.
* Your private health fund will cover the remaining 25% of the MBS fee.
2. Private Health Insurance
* Your private health fund agrees to pay a certain amount for medical services, which are above the MBS fee. This is
listed in their Gap Cover Schedule.
* Dr Cole will only charge what your health fund will pay as listed in their Gap Cover Schedule. We will deal directly
with your private health fund. Following your procedure we will submit invoices directly to Medicare and your health
fund for payment.
3. Known Gap Amount
* You will be required to pay a capped out-of-pocket fee for the portion of the provider’s fee not covered by Medicare
or your private health insurance. This is called the Known Gap Amount.
* Dr Cole’s rooms will provide an estimate to you, with payment required prior to your hospital admission. Payment
details and instructions will be on the estimate.
The Known Gap Fee applies only to the specific services outlined in the estimate. Additional services or treatments may incur additional Known Gap Fees. A fee applies for each return to the operating theatre. If applicable a final invoice for any outstanding fees will be sent to you following your discharge from hospital, with payment required within 7 days. Payment details and instructions will be on the invoice.
Team-Based Care and Separate Invoices:
Cardiac thoracic surgery involves a multidisciplinary team of healthcare professionals, each contributing their expertise to ensure the best possible outcome for the patient.
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)
Dr Cole’s team of doctors have fees which are separate to Dr Cole’s fees. However, they agree to follow the financial arrangement that Dr Cole chooses to use. For a Known Gap Arrangement, they will also submit invoices directly to Medicare and your private health fund for payment of their fees in accordance with the health fund’s Gap Cover schedule.
You may receive an invoice from each doctor directly for a known gap amount, which is not covered by Medicare or your health fund. You are responsible for paying this as an out-of-pocket expense. You will have separate financial arrangements and Informed Financial Consent with each provider.
Sometimes the Perfusionist will be required to be on standby for your procedure. A fee is applicable for providing this safety provision. The Perfusionist will contact you directly regarding their fees.
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.
Other Costs
Hospital or Facility Fees: This includes the cost of using the operating theatre, ICU, recovery room accommodation, nursing and other hospital services. These fees are usually billed separately by the hospital, directly to your private health fund. These are usually fully covered by Medicare and Private Health Funds, depending on your coverage.
Specialists: Other medical specialists (eg. Cardiologists, Respiratory Physicians, Endocrinologists) may be asked to consult during your care if considered necessary. They will individually have separate financial arrangements with you.
Additional Costs: There may be additional costs related to Pathology, Radiology, medical supplies, medications, and other services required for your care. These are usually partially covered by your health fund, depending on your coverage. You may get bills from these services, but in general, these are small amounts. We note however, that if a large number of tests are required, the costs can add up to large amounts.
We recommend that you contact your private insurance company directly to discuss your insurance cover, as well as your rebate eligibility and amounts for these additional services.
Estimating 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 Known 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 Known Gap arrangement.
Consent:
To participate in the Gap Cover arrangements and to deal directly with your health fund, the health funds require that you indicate you have consented to this arrangement. By submitting the form below, you acknowledge the following:
You have been informed of the Known Gap Arrangement and understand that this is an out-of-pocket expense.
You understand how Medicare and your private health insurance will contribute to covering the costs.
You accept the disclosed Known Gap amount and agree to pay this fee as specified.
You have had the opportunity to ask questions and are satisfied with the information provided.
Version Date 27 April 2020