How do I claim after a hospital admission?

After a hospital admission, there can be several different claims to process. The hospital itself and the doctors involved in your treatment will bill separately, and these claims don’t always follow the same process.

In most cases your hospital will submit their claim directly to the fund and your doctors will submit their claims directly to Medicare and your health fund.

Knowing where to send your bills, what documents you need and whether Medicare needs to process a medical claim first can make claiming after a hospital admission much easier.

This article explains how hospital and medical claims work, what to do if you’ve already paid a bill and the steps to take when you need to submit a claim yourself.

Key Points

• Your hospital and the doctors involved in your treatment will bill separately, and their claims may follow different claiming processes.
• Hospitals will generally submit their claim directly to your health fund, so you usually won’t need to submit the hospital claim yourself.
• Medical claims from doctors such as your surgeon or anaesthetist may need to be processed by Medicare before Phoenix Health can pay a benefit.
• If your doctor uses Access Gap Cover, they’ll submit the medical claim on your behalf and you’ll only need to pay any agreed out-of-pocket cost.

Do I need to make a claim after going to hospital?

Not always. In many cases, the hospital and the doctors involved in your treatment will submit their claims directly, so there may be little or nothing you need to do yourself.

Hospitals will generally submit their claim directly to your health fund. If a doctor involved in your treatment uses your health fund’s medical gap arrangement, they’ll submit their medical claim on your behalf.

You may need to take some additional steps if a doctor gives you an account to pay or you’ve already paid for a medical service yourself. Depending on how the doctor bills you, the claim may need to be processed by Medicare before your health fund can pay its benefit.

It’s also common to have more than one claim following a hospital admission, as the hospital and individual doctors involved in your care will bill separately.

What’s the difference between a hospital claim and a medical claim?

When you’re treated as a private patient in hospital, there are two main types of claims that result from your admission: the claim from the hospital and claims from the doctors who treated you.

Hospital claims

Your hospital claim relates to the costs charged by the hospital for your admission, such as your hospital accommodation and theatre fees. These are separate from the fees charged by the doctors who treat you while you’re in hospital.

The hospital will submit this claim directly to your health fund, which means you usually won’t need to make the claim yourself.

If you’ve paid a hospital account yourself, you’ll need to provide your health fund with an itemised hospital account and evidence of payment. Your health fund will contact the hospital directly should any additional information be required.

Medical claims

Medical claims relate to the fees charged by the doctors who provide your medical treatment while you’re in hospital. Depending on your admission, you could receive separate accounts from your surgeon, anaesthetist, assistant surgeon, physician or other medical practitioners.

These medical fees are separate from the hospital’s charges, even though the doctors provided your treatment while you were admitted to the hospital.

How these medical claims are submitted depends on how each doctor bills for their services. Some doctors will submit their claim directly through your health fund’s medical gap arrangement, while other medical claims will need to be processed by Medicare before your health fund can pay its benefit.

These separate medical fees are also why it’s important to understand who may be involved in your treatment before you’re admitted. Our guide to Informed Financial Consent (IFC) explains what to ask your doctors about their fees, while our guide to out-of-pocket costs explains the different costs you may need to pay when you’re treated as a private patient.

How do I claim medical bills from my surgeon, anaesthetist or other doctors?

Medical claims for treatment you receive as a private patient in hospital can be processed in different ways. The process depends on how the claim is submitted and whether your doctor participates in your health fund’s medical gap arrangement.

Claiming through Medicare first

If you receive a medical account from a doctor for treatment you received as a private patient in hospital, the claim needs to be processed by Medicare before your health fund can pay its benefit.

Submit the medical account to Medicare first. Medicare will assess the MBS item numbers, pay the Medicare benefit and provide a Statement of Medicare Benefit Paid by EFT.

Send this statement to your health fund so it can assess and pay the applicable health fund benefit.

Using a Medicare Two-Way Claim

Another option is to complete a Medicare Two-Way Claim and a additional Medicare claim form and submit it directly to Medicare.

Medicare will process its part of the claim and send the relevant claim information directly to your health fund under the Two-Way Agency arrangement. This means you don’t need to separately send your Medicare statement or complete a health fund claim form.

You can download the Medicare Two-Way Claim form from Services Australia.

When your doctor uses a medical gap arrangement

If your doctor participates in your health fund’s medical gap arrangement for your treatment, they’ll submit the medical claim directly on your behalf.

You don’t need to submit the medical account to Medicare or your health fund yourself. Your doctor will manage the claiming process and you’ll only need to pay any agreed out-of-pocket cost directly to your doctor.

It’s your doctor’s choice whether they participate in your health fund’s medical gap arrangement for your treatment.

What if I’ve already paid a medical bill?

If you’ve already paid a medical bill from a doctor involved in your hospital treatment, you can still claim the eligible Medicare and health fund benefits after the service has been provided.

The medical claim needs to be processed by Medicare first. Once Medicare has processed and paid its part of the claim, you’ll need to provide your health fund with the relevant Medicare Statement of Benefits paid by EFT so it can assess and pay the applicable health fund benefit.

What if I paid my doctor before my surgery?

Some doctors may require you to pay their fee before your procedure. Paying in advance doesn’t prevent you from claiming, but Medicare and health fund benefits can’t be paid until after the treatment has taken place.

Once you’ve had the treatment, submit the eligible inpatient medical accounts to Medicare. After Medicare has processed the claim, provide the required Medicare Statement of Benefits paid by EFT to your health fund so it can assess and pay its benefit.

What is a Medicare Statement of Benefits paid by EFT and where can I find it?

A Medicare Statement of Benefits paid by EFT is a record of how Medicare has processed your medical claim. Your health fund uses information from this statement to assess and pay its part of an inpatient medical claim.

For a claim that you’ve submitted to Medicare and Medicare has paid, you’ll need the Statement of Medicare Benefit Paid by EFT. This includes information such as the MBS item numbers, Medicare benefits paid and Medicare Schedule fees.

What if I haven’t paid my medical bill yet?

If you receive an unpaid medical account from a doctor involved in your hospital treatment, you’ll still need to have the claim processed by Medicare before your health fund can assess its benefit.

Unpaid or partially paid medical bills can results in a Medicare “pay doctor” cheque, that will get sent to you. You must pass the cheque onto your doctor and paid any remaining balance.

Once Medicare has processed the claim, provide your health fund with the required Medicare Statement of Benefits paid by EFT. Your health fund can then assess and pay its benefit towards the medical service.

You’ll be responsible for paying any remaining amount owed to your doctor after the Medicare and health fund benefits have been applied.

What happens if my doctor gives me a discount for paying early?

Some doctors may offer a discount if you pay your medical account within a certain timeframe. If you receive an early-payment discount, it reduces the fee you’re required to pay and reduces your final out-of-pocket cost.

The discount doesn’t change the MBS fee for the medical service. Medicare and health fund benefits are determined using the relevant MBS item numbers and claiming arrangements, rather than simply being calculated as a percentage of the fee your doctor charges.

For example, if your doctor’s original fee is $1,500 and they provide a $200 early-payment discount, your final fee is $1,300. If the combined Medicare and health fund benefits were $600, your final out-of-pocket cost would be $700. Without the early paymenty discount the final out-of-pocket would have been $900.

Your paid account or receipt should show the final fee charged and the amount you paid, along with the relevant MBS item numbers.

Why might my health fund need more information before paying my claim?

Sometimes your health fund may need additional information before it can assess and pay your claim.

This can happen if your eligibility for the treatment needs to be confirmed, you’re still serving waiting periods, a pre-existing condition assessment is required, or the information provided with your medical claim doesn’t match the information provided by the hospital.

Your health fund may need to request additional information from you, your doctor or the hospital before the claim can be finalised.

If more information is required, your health fund will let you know what is needed so the claim can continue to be assessed.

What happens after I submit everything?

Once your health fund has received everything it needs to assess your claim, it will process the claim and determine the benefits payable under your cover.

For medical claims, your Medicare and health fund benefits are applied towards the doctor’s fee. Any amount remaining after these benefits have been applied is your out-of-pocket cost.

If you’ve already paid the account, any health fund benefit payable will be paid to you. If the account is unpaid, your health fund will make the payment to the doctor.

Once your claim has been processed, you’ll receive a Member Benefit Statement showing the services claimed and benefits paid. Phoenix Health members can also view their claims history and benefits paid through the Phoenix Health app or Online Member Services.