The private health insurance hack that saved this mum $4,000

I'M THE first to admit that I don't have any idea what I'm actually paying for with my private health insurance. It's one of those things that I thought I should get in preparation for starting a family, so years ago, started paying for.

A few years later I fell pregnant, and even when the obstetrician explained to me that I'd be $5,000 out of pocket for her fees, I assumed I'd magically get it back somehow from my health insurer. I actually phoned my insurance company halfway through the pregnancy to ask cheerily when I could expect my lump sum refund, which is when the very depressing realisation dawned that I was never going to see the cash again.


Since the (lovely, but with a complication-free pregnancy, unnecessary) experience of having a baby through the private system, I've been unsure of whether any particular service is covered and just how much I'll end up paying.

That being the case, when my husband discovered he needed a nose operation to help him breathe better, we decided to go public. After spending a year on the waiting list, he got a letter giving him a week's notice that his operation had been scheduled. He doesn't have the kind of job where he can take sudden time off without notice, so he had to decline the date and move back down the list, at which point we realised that having it done privately was our best option.

Fast-forward to his appointment, where he was quoted $4,500 for out-of-pocket expenses. After a year of living on one income on maternity leave, it was really going to hurt the hip pocket, but we figured we didn't have much of a choice.

More out of frustration than anything else, I decided to phone our insurer and figure out once and for all why it was that we'd still be paying so much for a procedure that was supposed to be covered.


You're probably far more cluey than I, and therefore most likely rolling your eyes with contempt while reading this, but just in case you happen to be a health insurance noob like me, here's why you often pay so much more than what your insurer covers:

Basically, for a private patient in hospital, the government will pay 75 per cent of an agreed-upon price for the procedure. This is called the Medicare Schedule Fee. Your health fund will then pay the remaining 25 per cent, so in theory, that procedure is 100 per cent covered.

The problem arises, however, when doctors charge over the agreed-upon cost of that procedure. This is something they do frequently and with reckless abandon. When I spoke to our fund about the $4,500 in out-of-pocket costs my husband's doctor wanted to charge, they explained it was because he was charging five times the Medicare Schedule Fee. FIVE TIMES!


The help desk operator then informed me of a website called Healthshare, aimed at empowering Australians to make more informed decisions about their healthcare. One of the features of the site is that it allows you to search, by item code, for the procedures you need, and find a doctor in your area who performs them with either no gap (no out-of-pocket expenses) or a 'known gap' (a maximum of $500).

Within a week we saw a doctor in our area, told him the other quote was far too expensive, and he agreed to do the surgery for a 'known gap' of $500. Better yet, my husband could choose from a range of surgery dates that would fit in with his work/our childcare schedule, and just like that, we'd saved $4,000!


Since I discovered that it's possible to save so much on medical procedures, I've been telling everyone I know. So far, most people have been just as clueless as I was about what is actually possible when it comes to getting a better deal.
Here are a few tips on making the most of your private health insurance:

* Check the Healthshare website if you're with HCF (it only shows doctors who have a known gap agreement with HCF).
* If you're with a different insurer, phone them up and ask them which providers they have Gap agreements with. Most health funds have these agreements in place with certain providers.
* Remember that just because a doctor has performed a procedure for an agreed gap, it doesn't mean they will again; doing so is at your doctor's discretion so make sure you check with your doctor that it's something they can do. For us, this meant having to shell out for two separate specialist's appointments, but the saving more than made up for it.
* Talk to your surgeon about your ability to afford a proposed surgery. If the quoted amount is too high, tell them - they are at liberty to choose what they charge.
* If your health fund doesn't have any agreements with doctors, you can find a doctor who has an agreement in place with a different fund for the procedure you need, and switch your policy to that fund. Before you do, make sure you check with the new fund that there is no waiting period once you've changed over.
* Make sure you look into any additional costs, such as the cost of the anaesthetist. A lot of patients are stung by hidden anaesthetist costs, but you can check that they also participate in the known gap scheme before you agree to the procedure.
* Use the government comparison website to get ad-free information on which is the right fund for you
* Eat a doughnut. It won't save you money but all this thinking about health insurance has probably tuckered you out a bit. A sugar hit will help.

Since making the discovery that I actually had much more freedom than I thought when it came to my healthcare options, I'll never again accept an inflated price from a doctor without questioning it. The potential savings are too great.

The author has no association with Healthshare.

This article was originally published on Kidspot and is republished with permission.

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