Your right to know how much your treatment costs BEFORE you go to hospital is called your Informed Financial Consent. By working with ahm to understand what costs you're up for, you may be able to reduce them.
Your hospital should provide you with a written estimate of medical fees.
If they don't, it's your right to ask for one.
Your written estimate should include the following:
- Details of your hospital treatment, including a description and costs for each MBS item in
your upcoming procedure
Individual costs from any other specialists in your team, your anaesthetist, assistant surgeon, pathology and x-rays (radiology) or any other prostheses you may need
- Costs for hospital accommodation and any other services the hospital may charge you
It also outlines any out-of-pocket costs you may need to pay after you leave hospital
A declaration for you to sign. (Don't sign it until you have read this guide)
What are out-of-pocket costs?
Your ahm hospital cover can help towards most hospital fees, but any extra expenses you may need to pay are known as out-of-pocket costs. Some common out-of-pocket costs include:
Your hospital excess
Costs for pharmaceuticals or services not covered (either partially or in full) by our agreement with your hospital
Costs for treatments that aren’t recognised by Medicare
Any difference in costs between your specialist fees and the benefits you might be paid toward them from Medicare and ahm. This is known as 'the gap'
Gapcover helps reduce the gap
For any inpatient specialist bills, Medicare pays 75% of a pre-determined ‘standard fee’ known as the Medicare Benefits Schedule (MBS) fee – and ahm pays the remaining 25%.
When specialists charge more than the MBS fee, this extra amount is called ‘the gap’. By choosing a specialist who participates in GapCover for your claim forming part of your treatment, your out-of-pocket costs from that specialist are capped at $500.
Specialists can choose to participate in GapCover on a per claim, per treatment and per patient basis. If you’re being treated by more than one specialist (e.g. surgeon and anaesthetist) their participation is at each individual specialist’s discretion.
If a specialist does not participate in GapCover for your treatment, you have the option of finding one that does. For more help on this, please contact us
How to limit your out-of-pocket expenses
1. Choose an ahm partner hospital or provider
We have agreements in place with ahm partner hospitals, this limits the costs you will need to pay for
hospital treatment. If your specialist works at a few hospitals, check if they’ll treat you at an ahm partner hospital. Find your nearest ahm partner hospital or provider at ahm.com.au/find-a-provider
2. Ask our '7 Questions for your specialists before you go to hospital'
To make your claim simple, we've put the important information we need from your hospital on one page.
Print it off to take to your next appointment at ahm.com.au/7questions
3. Contact us when you have these answers
When you have these answers ready to go, live chat with us or call 134 246 weekdays, 8am – 7pm (AEST/AEDT). We’ll check your admission date and the following:
Your cover includes the treatments you need and you’ve served your waiting periods
Your premium payments are up to date
Any excess or co-payment you’ll need to pay on admission
If you need to pay any other out-of-pocket costs
In an emergency
In an emergency, your specialists should tell you everything you need to know as soon as possible. If they can’t get this information to you personally, they’ll need to tell your relatives or someone who can act on your behalf.
If you're treated in an Emergency department and you're not admitted to hospital, you'll be an outpatient and we won't pay any benefits towards the treatment you receive. However, a rebate may be claimable from Medicare for outpatient services.
How do I deal with unexpected fees?
If your bill is higher than expected, first go back over your written estimates. If your bill is different to your estimate, contact your specialist to talk about any changes. If you get stuck, give us a call on 134 246.
Know your rights
As a private patient you’re entitled to:
Know the full cost of your in-hospital treatment
Know about any out-of-pocket costs you could be up for
Ask for this information in writing from your specialist, hospital or us
Ask your specialist if they’ll participate in GapCover
Choose your specialists and hospital
Make a complaint if you’re rights aren’t upheld.
If you need help understanding your rights, your medical bills or your hospital cover, please get in touch with us. You can live chat with us or call 134 246 weekdays, 8am – 7pm (AEST/AEDT)
If you're still worried about your bill or treatment, you can call the Private Health Insurance Ombudsman
on 1800 640 695.
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