8.7.4 Fees (What you Pay at the Doctor)
Description
This article is from the soc.culture.australian FAQ, by Stephen Wales with numerous contributions by others.
8.7.4 Fees (What you Pay at the Doctor)
Generally, patients are charged by doctors on the basis of the
"Schedule Fee". This refers to a schedule of standard fees for
medical procedures and services.
The Schedule Fee was originally a standard fee set by the doctors
professional organisation (the Australian Medical Association - AMA)
however in recent years (particularly as the influence of the AMA has
declined) it has come to be set by agreement amongst the State and
Federal Government.
The exact amount a particular patient will be charged is based on the
Schedule Fee, but could be modified by one or more of the following
factors:
- Does the doctor "bulk bill"
In this case, the patient pays nothing.
Since the introduction of Medicare in 1975, many doctors have moved to
"bulk billing". This is a procedure where the doctor bills the
Medicare scheme directly rather than the patient. The downside (for
the doctor) is that they only get the Medicare payment of 85% of the
schedule fee. The term "bulk" is used because the doctor can simply
issue a single invoice at the end of the month, rather than separately
billing every patient.
If the doctor doesn't bulk bill, the patient would pay the bill and
then seek reimbursement from Medicare.
- Is the patient privately insured
In this case the patient will generally pay according to his or her
insurance cover. This differs from policy to policy but is usually
nothing, unless the doctor charges more than the schedule fee (see
below).
However, the doctor in this case, gets paid the full Schedule Fee,
and a bill is issued to the patient. The patient would then pay the
bill and seek reimbursement for 85% of the fee from Medicare and the
rest from the insurer. (Although most insurers have a deal with
Medicare so their clients need only make a claim through them rather
than stand in two queues.)
- Does the doctor charge more than the schedule fee?
Some doctors (whether through ability, reputation, or greed) charge
more than the schedule fee. In this case, all patients pay the doctor
direct and seek reimbursement from Medicare or their insurer.
Typically, the patient is out of pocket to the extent to which the
doctor charges above the schedule fee.
Summary:
- patients without private insurance usually go to bulk billing doctors
and pay nothing.
- patients with private insurance pay up front and get the money back
(but often not all of it) from their insurer.
(An aside. The scheme above has placed economic pressure on doctors
over the last 20 years, and many doctors now work in modern 24 hour/7
day clinics which bulk bill and treat both insured and uninsured
patients. Such clinics have proved to be very profitable and efficient
and now appear in even the "best" suburbs.)
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