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Complex Medibank/Medicare qn
Unexpected $2500 OOP!!


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#1 Lokum

Posted 15 February 2013 - 12:19 PM

So I was in labour for 9 hours and stupidly called for an epidural in my private hospital.

Anaesthetic  came and administered it, advising that there would be an OOP because it was out of hours call (around 9pm.) I think she said around $750 OOP, or maybe I thought that because that's how much it was for my midnight spinal last time.

Epi didn't work.  I could still feel every contraction and could feel when a midwife accidentally scratched my belly while adjusting the CTG monitoring belts.

10 mins later, OB said we'd have to have a c/s. Obviously, this epi hadn't worked sufficient to get me through surgery, so I had to have a spinal as well. (If I'd only waited 10 more minutes  cry1.gif )

Anaesthetist said sorry, but because we're now doing a diff kind of anasethetic, there'll be another OOP for this.

I thought, great, now the OOP will be up around the $1500 mark.

Bill came (2 invoices, one for epi & one for spinal), with total 8 items, and bill of $3490. Sent it off to Medicare who passed it on to Medibank. Medicare have provided cheque for around $890 - 75% all the scheduled fees for those services.  Medibank have provided cheque for $272 (25% of the scheduled fees.)

This leaves me with a bill for approx $2500 just for anaesthetic services. I'm flabbergasted. We have mid level hospital cover with no excess. I didn't get a bill from my OB for the c/s - Medibank and Medicare covered the lot.

How come Medibank isn't covering more of the actual cost of these services? Is it too bad so sad, or is there any chance they've stuffed up?

#2 bark

Posted 15 February 2013 - 12:24 PM

Sounds right to me unfortunately. Yr private health only covers the gap not paid by Medicare according to their schedule. Private health is basically to cover your hospital stay - yr accommodation.

#3 Bluenomi

Posted 15 February 2013 - 12:30 PM

You've got a gap because you were charge above scheduled fees. PHI is only legally allowed to pay upto the schduled fee, the rest is up to you to pay. It sucks which is why people try and get no gap doctors but that doesn't work in emergency situations.

Anaesthetists are some the most expensive doctors so their out of pocket is usually huge.

#4 MrsLexiK

Posted 15 February 2013 - 12:33 PM

QUOTE (Lokum @ 15/02/2013, 01:19 PM) <{POST_SNAPBACK}>
How come Medibank isn't covering more of the actual cost of these services? Is it too bad so sad, or is there any chance they've stuffed up?


I don't think they have stuffed up, your OB should have made you aware of the costs.  We were given a sheet with the max OOP expenses we would face for epi's or c-sections and it had different amounts for different days.  If I was booking in for an induction with an epi or a scheduled c-section I would be able to call up and find out the costs and see if I could work around one that works with my health fund for gap, however if it is going into labour normally you get what they charge you.

I am very thankful that my OB is a gap provider with medibank and my mangement fee is costing around $600 - $800 (depending on which hospital we have to go to now) and that is before the medicare rebate.  I have budgeted for the epi or c-section costs

#5 Rach_V

Posted 15 February 2013 - 12:34 PM

It does sound right unfortunately. Your out of pocket costs depend on how much each individual doctor charges as well as whether or not they participate in your health fund's "gapcover" schemes, where the health fund will pay higher rebates than the usual 25% (there are limits, rules, etc for participation in such schemes).

If you didn't get a bill from your ob, it sounds like your ob participates in Medibank's gapcover scheme and accepts their gapcover schedule as full payment.

You could call the anesthetist and ask them if they do use Medibank's gapcover, you may still have to pay out of pocket costs but these can be reduced if they do use it. However, I believe that Medibank cap the total amount payable by the patient to $500, which means the dr has to reduce their fee significantly in many cases, hence a lot of them won't participate.

The world of private health insurance is complex. Even if you had the highest possible level of private health insurance, you would often still have out of pocket costs associated with your surgery.

Edited by Rach_V, 15 February 2013 - 12:35 PM.


#6 IsolaBella

Posted 15 February 2013 - 12:38 PM

QUOTE (bark @ 15/02/2013, 01:24 PM) <{POST_SNAPBACK}>
Sounds right to me unfortunately. Yr private health only covers the gap not paid by Medicare according to their schedule. Private health is basically to cover your hospital stay - yr accommodation.



QUOTE (Bluenomi @ 15/02/2013, 01:30 PM) <{POST_SNAPBACK}>
You've got a gap because you were charge above scheduled fees. PHI is only legally allowed to pay upto the schduled fee, the rest is up to you to pay. It sucks which is why people try and get no gap doctors but that doesn't work in emergency situations.

Anaesthetists are some the most expensive doctors so their out of pocket is usually huge.



Yep this is the case.  DS2 is about to have Grommets put in again. $1,050 for  ENT and we get back $360 and $700 for anaesthist which we get back $350. As PP said PHI only covers the gap between the Medicare rebate and the scheduled fee.

For my cs the OB was no gap, but Anaessthest OPE were from a small $250 for out if hours emerg one to $850 for the one which was day scheduled. They just billed at different rates.



#7 Soontobegran

Posted 15 February 2013 - 12:39 PM

Unfortunately many women have both an epidural in labour and then a spinal if a C/S is needed and that will mean two separate item numbers.
I understand the fact that your epidural didn't work would make it really difficult to cough up the money for it but the equipment and the drugs involved are pretty costly. It would be nice however if your anaesthetist could show some empathy and lower his/her fees and I would actually approach him/her and try to negotiate these.

What I would probably do is send in the two cheques from Medicare and Medibank with an accompanying letter asking for an explanation of the costs and whether there is any room for 'movement'. Some will show compassion but it is well known that the anaesthetist bill is often the biggest in obstetrics.
What you have got back as rebate does sound about right but they will only rebate you on the scheduled fee so if the anaesthetist ups his charges you will be more out of pocket.

I know this is cold comfort Lokum but my anaesthetist 30 years ago for my eldest DD left me $900 out of pocket and that was a huge amount of money back then. It seems nothing changes.

Hope they will be kind, do not be afraid to ask for a discount or at least a payment plan.
Good luck.

#8 Lokum

Posted 15 February 2013 - 12:40 PM

Thanks everyone. It is as I thought  sad.gif .

Bad luck that I was scheduled for a c/s but he decided to come early and I ended up with night time emerg c/s... I believe the anaesthetist I would have had for the scheduled c/s would have been no-gap.

Bad luck also that I had an epi AND a spinal, and double the hit to my pocket sad.gif

You don't really budget for that scenario. Lucky the baby is absolutely lovely, and very healthy  biggrin.gif

#9 Lainskii

Posted 16 February 2013 - 07:57 AM

I was annoyed as I had a planned CS due to issues and the day before the anaesthists secretary rag and said it the bill would be approx $800, when it came it was $1400. My op didn't take any longer than normal and had no issues.

#10 ednaboo

Posted 16 February 2013 - 08:11 AM

You should at least be able to claim a tax rebate for this under "medical expenses over $2060".  ATO.

#11 barrington

Posted 16 February 2013 - 08:21 AM

That sucks OP!  Most anaesthetists I know would only bill you an out of pocket for the first procedure.

For anyone that is interested, here is a link to a page explaining how private anaesthetic fees are calculated.

And for a PP - anaesthetic fees are calculated on a time basis.  So if your operation did take longer than your estimate was based on, then your fee would be higher.



#12 Soontobegran

Posted 16 February 2013 - 08:29 AM

QUOTE (barrington @ 16/02/2013, 09:21 AM) <{POST_SNAPBACK}>
That sucks OP!  Most anaesthetists I know would only bill you an out of pocket for the first procedure.

For anyone that is interested, here is a link to a page explaining how private anaesthetic fees are calculated.

And for a PP - anaesthetic fees are calculated on a time basis.  So if your operation did take longer than your estimate was based on, then your fee would be higher.


You are lucky barrington, I admit to not knowing too many that will do that original.gif

The problem with this is that the anaesthetist will put their own dollar value on top of the AMA value and since the AMA value is more than the scheduled fee value and this leave an enormous gap for so many.

#13 IsolaBella

Posted 16 February 2013 - 09:33 AM

QUOTE (ednaboo @ 16/02/2013, 09:11 AM) <{POST_SNAPBACK}>
You should at least be able to claim a tax rebate for this under "medical expenses over $2060".  ATO.


The threshold has increased to $5k for 2012/13



#14 tibs

Posted 16 February 2013 - 09:51 AM

If it makes you fee any better I had a straightforward 30 min scheduled c-sec and had an OOP anaesthetist bill around that size and that was just for the spinal.  I had a different anaesthetist for my second scheduled c-sec and only had approx $500 OOP bill.  I had no OOP charge at all with my 3rd scheduled c-sec.  All 3 with the same Ob, same private hospital, all scheduled.  That was the only bill I had, Ob, assisting Ob and hospital were all covered.

#15 ednaboo

Posted 16 February 2013 - 10:26 AM

QUOTE (lsolaBella @ 16/02/2013, 10:33 AM) <{POST_SNAPBACK}>
The threshold has increased to $5k for 2012/13

Only for high incomes - $168,000 for couples apparently.

#16 Lokum

Posted 16 February 2013 - 11:42 PM

QUOTE (ednaboo @ 16/02/2013, 09:11 AM) <{POST_SNAPBACK}>
You should at least be able to claim a tax rebate for this under "medical expenses over $2060".  ATO.


Yeah. Another sucky thing is that we had huge OOP in 2012 because of IVF early in the year, then obstetric and anaesthetic! fees later in the year - total around $7500.

However, these were split over the 2011-12 and 2012-13 financial years, so we'll have to meet the threshold for the tax rebate in each financial year before we can claim, and we'll probably get 75 cents or something back...

I know there are worse problems to have, but gahhh!

#17 Wildence

Posted 17 February 2013 - 12:09 AM

QUOTE (Lokum @ 15/02/2013, 01:40 PM) <{POST_SNAPBACK}>
Lucky the baby is absolutely lovely, and very healthy  biggrin.gif

I was just going to say that! Thank god to a healthy baby original.gif

I had to do D&C one year ago, and ended up 1k OOP for such a small and common procedure, i can totally see how frustrating it is that you have to pay that much! However at least you have a healthy baby in your arms as a result of that.


#18 tibs

Posted 17 February 2013 - 09:58 AM

QUOTE (Wildence @ 17/02/2013, 01:09 AM) <{POST_SNAPBACK}>
I was just going to say that! Thank god to a healthy baby original.gif

I had to do D&C one year ago, and ended up 1k OOP for such a small and common procedure, i can totally see how frustrating it is that you have to pay that much! However at least you have a healthy baby in your arms as a result of that.


Yes same, I was actually more OOP for the D&C before my last pregnancy than I was for my last birth (scheduled c-sec).  And no baby to take the sting out of it sad.gif  Now that sucks.




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