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Member Insider - Your rights as a Private Patient

by CBHS | Apr 10, 2017
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Welcome to CBHS first Member Insider! This will be a recurring series covering the ins and outs of Private Health insurance to ensure our members are informed of their options and opportunities when it comes to their coverage. If you have any questions or topics you’d like explored as part of Member Insider, please email CBHS at help@CBHS.com.au with Member Insider as your subject line.

Should I use my Private Health Insurance when I am admitted to a Public Hospital?

The answer is not simple. Some public hospitals have been aggressively persuading Health Insurance members to use their health insurance in public hospitals, but members have not then  seen any additional benefit in doing so.

Public hospitals are operating on tight budgets. This means any other source of funding, including private health insurance payments, are vigorously sought.

Under Medicare, any Australian resident admitted as a public patient in a public hospital is entitled to treatment by a doctor appointed by the hospital, at a time determined by the hospital. Medicare pays for your accommodation, meals, medical and nursing care, theatre and other fees related to your treatment. This means that anyone that chooses to be admitted into a public hospital as a public patient (without using their health insurance) receives full coverage from Medicare directly.

Will I get better treatment if I use my Private Health Insurance when I am admitted in a Public Hospital?

If you choose to use your private health insurance when admitted to a public hospital, in most cases this may not guarantee any improved or special medical treatment.

In public hospitals, private rooms are generally allocated to people who medically need them the most. Whilst you can request a private room as a private patient, you may not always be allocated one depending on availability. The hospital may also transfer you from a private room to a shared room during your stay if another patient has a greater need for the private room.  You also have the option to use your doctor of choice, should you be admitted privately in a public hospital, however depending on your illness or condition and the size of the hospital, this may be the same doctor who would have been allocated to you by the hospital as a public patient.

Should you elect to use your health insurance in a public hospital, that there may be costs for you to pay that may have originally been covered for free under Medicare. These costs include excess payments, and additional out of pocket charges that your doctor may charge for your treatment. However, because public hospitals get a financial advantage by admitting private patients, they often agree to pay for any out of pocket expenses you will be charged for using your insurance.

When should I use my health insurance in a Public hospital?  Members should consider whether it’s worth using their cover by asking the hospital a few questions when being admitted.  The answers should then give you an indication as to whether there is benefit for you to use your insurance or not.

  • How will I benefit from electing to be a CBHS member in this public hospital? 
  • Will there be any different treatment given to me as a private patient?
  • Can you guarantee me a private room for the length of my stay?
  • Can I choose my own doctor?

How will I know how much my out of pocket costs will be? Knowing how much your treatment is going to cost is called Informed Financial Consent (IFC). You have the right to be provided with IFC from both your doctors and the hospital.

Ask your treating doctor or specialist wherever practical how much their fee will be, and if you will need to pay a gap. For major treatment, this information should preferably be provided in writing.

You may have more than one doctor involved in your treatment, for example, a surgeon and anaesthetist. Your surgeon should be able to advise who else will be treating you and how you can contact the other doctors to seek fee information from them.

You may have lower or no out-of-pocket medical costs if your treating doctors elect to use CBHS’ Access gap scheme. You are entitled to ask your doctors if they will use the scheme. It is completely up to your doctor to use the scheme. CBHS has no input into this decision.

Ask CBHS 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 may 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 will also need to ask your doctors to fill in medical certificates to determine if benefits will be paid.

Ask the hospital whether they have an agreement with your private health fund 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.

What if it is an emergency? There will be circumstances, where it will not be possible for your doctor to obtain 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.

So, it’s my decision? Members have the right to use their health insurance when they see fit.  If you cannot see the value of using your health insurance in a public hospital, you are well within your rights to not use your health insurance and simply be admitted as a public patient. Public hospitals must treat you as a free public patient if you want that, regardless of your insurance status. But if you want to use your insurance, that that decision should not be made until you or your legal guardian is fully informed of the consequences of that choice.  

What if I change my mind? You’ll only be able to change how you’re admitted if something unexpected comes up, so it’s important to have all the information you need before you make your choice.

Will it affect my choice affect my contributions? The public hospital practice of encouraging patients to elect to use their private health insurance means insurers pay public hospitals  instead of state and federal governments picking up the tab. As a result public hospitals now employ marketing people who direct the admission staff and visit the patients in hospital to convince them to use their private health insurance. Ultimately, this cost shifting puts pressure on private health insurance contributions.