Having an out-of-pocket expense or gap charged by a doctor can be frustrating especially if you weren’t expecting it.
Phoenix Health Fund has contracts with thousands of Doctors across the country through the Access Gap Cover Scheme, and
members who use these doctors enjoy lower or nil out-of-pocket expenses through using their services.
Give yourself the best chance to remove or reduce out of pocket expenses by simply following the steps below:
- Choose a doctor that participates in the Access Gap Cover Scheme – Doctors in this scheme agree to reduce out
of pocket expenses to members. To learn more about Phoenix’s Access Gap Cover Scheme, click here, and to search for doctors under this scheme,
simply click here. Remember, it’s always a good idea to talk about the Access Gap Scheme when you’re first considering which doctor to choose. - Request a quote from your doctor – It’s your right to know what you are being charged. Ask for a written quote
(informed financial consent) so you can understand if your doctor is charging above the standard Medicare fee. - Call our office and share your quote with us – We’ll let you know if the charge quoted is reasonable or could be
unusual. If it is more than you expected to be charged, you can request to change your doctor if desired.
Why do people get charged out of pocket expenses when they are purchasing Private Health Insurance?
The Government sets a fee for every medical service in the Medicare Benefits Schedule (MBS). When you have hospital treatment as a private patient, Medicare will pay 75% of the MBS fee and your private health insurer will pay a minimum of 25%.
Gaps for doctors’ fees come about when your specialist, and/or the other doctors involved in your hospital care, charge more than the MBS fee. Your insurer can pay more than 25% of the MBS fee, if the doctor is prepared to use its “gap cover arrangements” (like Phoenix’s Access Gap Cover Scheme). In this circumstance, you will either have no gap to pay, or you will be informed in advance about any gap. Many doctors are prepared to use gap cover arrangements.
Doctors can choose, on a case-by-case basis, whether they wish to use an insurer’s gap cover arrangements. If you doctor chooses not to use your insurer’s gap cover arrangements, you would be required to pay the gap between the MBS fee and the total charge out of your own pocket. In these situations, Phoenix advises members to consider their Doctor options in their area, and consider choosing a doctor that operates under the Access Gap Cover Scheme.
For more information on this, please read the fact brochure published by the Private Health Insurance Ombudsman’s office by clicking here or simply contact us.
