Why won't they tell me?!!

Hi All,

Yesterday I received a confirmation letter from my surgeon for my initial consultation (next Friday - yay!).

In the letter it listed a forecast of the total costs including the procedures and appointments with item numbers saying that I should contact my PHI to make sure I'm covered.

Well, yesterday I did just that. I rang Medibank Private and asked how much I would get back for item number "x". They wouldn't tell me! They said they didn't know - WTF? I said, how can you not know when you are the one paying me? She said for me to ring Medicare and they can tell me what the actual cost of the item number is and how much I can expect to get back.

That just doesn't make sense to me. Medicare can tell me how much Medicare will cover but how on earth do they know how much my PHI will give me back?

I got off the phone thinking WTF! I'm their customer - I'm entitled to know what I'm covered for.

Anyone else had this from the PHI company?

Sorry about all the 'WTF's'. I'm really angry about it now though.

Cacooned

You will get 80% of the recommended scheduled fee back from medicare and your PHI usually covers the other 20%.
Just remember the scheduled fee for medicare procedures is no where near what the surgeon will charge you.
YOu can look up on the MBS online if you have the medicare item number. MBS online is down for maintenance today until after 1pm or something so try later.

Thanks Kylie :). Will check on that later on today.

Cacooned

I know! I've never had to use our PHI, so was confused how it all worked. They were hardly helpful! My PHI told me I would get back $900 odd for item 30518. I was covered for the stay in hospital, and theatre fees, etc., I will be out of pocket approx $4k

Hi there cacooned, you can check yourself at http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Medicare-Benefits-Schedule-MBS-1
you enter the item number and the results show the scheduled fee, the 75% benefit and the 85% benefit. Medicare covers the 75% and your health fund covers the remaining 25% up to the scheduled fee. Anything over that is 'the gap' and that's what you'll have to pay out of pocket. Hope this helps,

Thanks guys. I went and had a look (thanks for the link TL Helena, would've taken me ages to find that). You're all so helpful.

Hi cacooned,

It is very weird that Medibank wont give you those details, however I do know that when i went to my surgeon I gave them my details (health fund) and they checked on my level of cover and prepared a quote for me, The most medibank could do for me was tell me that they did provide cover for the item under my level of cover.

I think you may be heading for disappointment if you keep trying medibank - bes try your hospital and doctor for the pricing you will need to pay.

Hi Cacooned

The way it works is that there is the recommended scheduled fee for the Item No of which Medicare will pay back around 75% and your PHI will cover the remaining 25%. Please bear in mind though that the schedule fee is likely to be $'000s less than what you are actually being charged by your surgeon for the procedure.

You can use the following web address to look up the Item No and it should give you the break down (I've found it useful now that I'm looking into the "reconstruction" of the body phase).

http://www9.health.gov.au/mbs/search.cfm?pdf=yes

Just type in the Item No and it will give you some information about it.

Cheers
Gail

Thanks Gail :)