What is informed financial consent?
Before you receive your treatment, you are entitled to ask your doctors, CBHS, and your hospital about the full cost of your treatment, including the likely out-of-pocket expenses (gaps).
Informed financial consent (IFC) is the provision of the breakdown of all expected costs that you may incur.
CBHS recommends that you ask for this information to be provided to you in writing prior to your treatment or admission to hospital.
Who will be involved in my treatment?
Your principal doctor will talk to you about his or her fees for any proposed treatment.
Ask your doctor about fees for other doctors, such as the anaesthetist and assistant surgeon. If they can, your doctor will explain the fees of other doctors involved in your care or they will provide you with their contact details so that you can find out about their fees, and about any out-of-pocket costs that you might have to pay.
How do Doctors’ fees work?
In Australia, doctors are free to decide how much to charge for their services. Fees vary because doctors have to take into account their particular costs in delivering services and may have differing views about what represents a reasonable return for their time and skill.
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. CBHS will pay 25% of the MBS fee.
CBHS can pay more than 25% of the MBS fee, if the doctor is prepared to use CBHS’ Access Gap Cover (AGC) 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 the AGC Scheme.
Doctors can choose, on a case-by-case basis, whether they wish to use CBHS’s AGC Scheme. If your doctor chooses not to use CBHS’s AGC Scheme, you would be required to pay the gap between the MBS fee and the total charge out of your own pocket.
What is a gap?
If you must go into hospital for surgical or medical care, there may be an out-of-pocket cost or medical gap that is not covered by Medicare or CBHS. A medical gap is the difference between the combined amount paid by Medicare and CBHS for a medical service, and your doctor’s fee.
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.
How can I find a Doctor who will use CBHS’s Access Gap Cover Scheme?
You can find specialists who have participated in Access Gap Cover with CBHS through Healthshare. But remember, it is up to you to ask the doctor if he or she will participate in your case. This method of billing is at the Doctor’s discretion.
How will I know if costs change?
In an emergency or if something unplanned happens during your procedure, there may be additional costs to you that could not be estimated in advance. This information will be provided to you as soon as possible after treatment occurs.
What if I need a prosthesis?
Prostheses include pacemakers, defibrillators, cardiac stents, joint replacements, intraocular lenses and other devices that are surgically implanted during your operation in hospital. Before surgery, your doctor will tell you if one is required, why you need it and whether it will cost you anything. There are some prostheses available that won’t cost you anything, but if you have an out-of-pocket cost to pay, your doctor will explain why this prosthesis is the best one for you.
Do I have to ask the hospital for IFC?
Yes! You need to know whether they have an agreement with CBHS and whether you will have to pay any gaps or extra costs. Your hospital should perform a membership eligibility check with CBHS before you are admitted and seek your informed consent to incurring any out-of-pocket costs associated with your admission. This information should preferably be provided in writing.
Do I have to call CBHS?
Yes! You need to know whether your policy will cover the procedure, and whether you will need to pay an excess, co-payment or any other charge associated with the treatment. CBHS will need you to obtain the Medicare item numbers your doctor will be using to give you an accurate quote. If you are within waiting periods, you may also be required to ask your doctors to fill in medical certificates for assessment by the CBHS of whether benefits will be paid.
IFC in Emergency Situations
There will be circumstances, for example emergency admissions, where it will not be possible for your doctor to provide you with IFC before the service is provided. In that case, information should be provided to you as soon as possible after the service is provided. In circumstances where it’s not feasible to provide information directly to you before or after treatment, your doctors may provide the information to a near relative or representative acting in your interests.