The Truth About Gap Fees


If your surgery bill has left you gobsmacked, we don’t blame you. But there is something you can do about it.

When someone is diagnosed with a potentially life-threatening illness, going through surgery or treatment is more than enough to deal with. Money is rarely on the patient’s mind; it’s an afterthought at best.

But what comes after surgery can be shocking for many. We’re not talking about surprise symptoms or side-effects. We’re talking about being hit with an unexpected (massive) bill.

The breakdown of a surgery bill is not something that the average person would question – but in reality, you should. Don’t go into surgery blindsided by a doctor or surgeon you thought you could trust.

It’s not uncommon to be hit with an out-of-pocket bill of 5, 10 or even 15 thousand dollars. Some people are even paying beyond this, despite having private health insurance and being backed by Medicare.

Who’s to blame?

Too often, we’re quick to blame the insurer. Medical providers are considered experts, so who are we to question them? Surely they have our best interests in mind? And because they’ve studied medicine and we haven’t, we trust them by default.

We’re not saying they aren’t trustworthy. But this default trust seems to leave your insurance provider as the one to blame. Why are we pointing fingers at health funds when, after all, it’s the surgeons that rely on their patients for an income? When consumers are hit with huge out-of-pocket expenses, insurance providers often get a bad rap that stems from a false perception.

For instance, there is no standardised treatment pathway for men with prostate cancer. Often, the GP will refer these men to surgeons when there is a potentially better option out there for them: radiotherapy. The issue isn’t necessarily in the referral; it’s the fact that some surgeons aren’t likely to send a patient to the radiation oncologist. They would lose a customer.

The reality

Many surgeons are offered higher rebates from health funds provided they sign a contract to confirm they will not charge their patient a gap fee.

It seems straightforward but unfortunately paves the way to an issue not everyone is aware of. Though it is illegal for surgeons to charge patients ‘booking’ or ‘administration’ fees, this doesn’t stop some from cheating the system.

Indeed, patients should be charged a surgical fee and nothing more. On top of anaesthetist, theatre, and consultation fees, some are being charged over $15,000 by surgeons despite having private health cover. It is due to this ‘booking fee’ that the gap becomes so significant.

In reality, many patients find, in hindsight, they could have had the same surgery, potentially with a better outcome at a fraction of the cost.

What you can do

These massive out-of-pocket expenses are especially bad for paediatric specialists and bowel surgeons. It’s also not uncommon for a cancer patient to be massively overcharged.

Keep in mind that where you live may affect your out-of-pocket health expenses, too. For example, for hip replacements, 69% of people in NSW were charged more than $2000. For WA residents, 40% and Victorian residents, 25%.  

The problem is largely connected to medical practitioners setting their own fees and obscuring costs. But there are things you can do to save yourself from being overcharged.

Ensure you shop around and get a second, even third, opinion when it comes to your health. By doing this, you could be getting more out of your health insurance and ultimately be paying less for the same procedure. Not to mention, when you have a serious or pressing health concern, multiple opinions can provide peace of mind, foster trust and confirm a correct diagnosis and suitable treatment plan.

If your surgeon encourages multiple opinions, even better. This is often a good sign that he/she has your best interests in mind, rather than their next paycheck.

If you notice a fee you’re unsure about on your surgery bill, ask your doctor what it was actually for and what the clinical or medical relevance of it is. If you receive an unsatisfactory response, it is well within your rights to refuse to pay and discuss the fee with your health fund.

Final Thoughts

Having surgery is rarely a pleasant experience. It can be painful and costly, but in so many cases it is necessary. For these reasons, you want the best care, the quickest recovery and the greatest outcome possible. Before and during the treatment process, keep in mind:

  • The surgery fee size has no link with the quality of service you receive.
  • It’s your right to get a second opinion, or multiple if you wish.
  • Surgeons charging booking or administration fees are doing so illegally.
  • If you have private health cover, yet you’ve been hit with a huge out-of-pocket bill, know that there is a cheaper way to access quality treatment and care.
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