Confused over access gap cover?

Hi :)

I am looking into getting a sleeve though I don't even have private health insurance yet.

I have had a look at a few insurance companies (Defence health and Navy health) and both state that they have 100% cover over doctor's fee's ect if the doctor has access gap cover.

Just wondering if any of the doctors that do gastric sleeve's have access gap cover?

I have looked and both insurance compaines have agreements with all hospitals that the doctors I have looked into.

Any info would be great






AmandaJ

I am yet to find a single surgeon outside a couple in WA and even then I am not sure if they do still whom cover you like that. tho you can strike it lucky when it comes to your gas guy. But I would stick to somebody like medibank or one of the other big ones to try and get that.

All insurance make you wait out 12 months. You need hospital ONLY cover no extras will be of any use to you for the surgery. Nor do you have to pay family cover even if you have a partner and or children you can just take out single cover saving you half the money.

Do phone any insurance you want and ask what is the MINUM cover you need for weight loss surgery as some health insurance have it only on their highest level of hospital cover, so it pays to shop around. And yes it is perfectly normal for people to phone them and ask what level of cover they need for a surgery.

applesauce

Applesauce: Medibank and MBF don't have an agreement with the hospital. (not to sure what that means though)

Thanks on the tips for phoning around :) I will see what I can find out :)

Ok I received an email from navy health with the following:

Lastly, in relation to your medical accounts (surgeon, assistant surgeon, anaesthetist, pathology, radiology, etc), you will be covered 100% of the Medicare Benefit Schedule (MBS) for all item numbers used, provided you were treated as an inpatient. Medicare sets the schedule fee and benefits are paid as follows:



75 per cent by Medicare


25 per cent by Navy Health


Unfortunately, doctors are able to charge whatever they wish. This subsequently can leave our members with out of pocket expenses. We strongly suggest you speak to your doctors in relation to their charges prior to being treated.


In order to help alleviate or eliminate any out of pocket expenses, Navy Health offers the Access Gap Scheme. This allows Navy Health to pay more than 25 per cent of the MBS. This is something that needs to be discussed directly with your Doctors. In order to participate, the Doctor needs to be registered with the Australian Health Service Alliance (AHSA). You can find a list of providers who are registered on our website, or by following this link. http://www.navyhealth.com.au/member-services/provider-search . It is important to note however, that doctors are able to opt in and out of this scheme of their own accord, hence the reason why it is important to discuss this directly with your doctors.



So from what I understand the only fee's I would have is the access for the health insurance if I decide to go that way and the out of pocket expences from the actual doctor??????

Amanda - just wanted to share with you a snippet from an email my PHI provider sent me - when I asked about agreements between dr's and PHI

"It’s the doctors choice whether they chose to participate in agreements with the health fund if the doctor doesn’t participate in an agreement then we are restricted to benefits as per the MBS schedule, if a doctor chooses to participate in an agreement then legislation allows us to pay higher benefits."

Basically, my interpretation is - some dr's choose to sign an extra agreement with some PHI - which allows the patient to get a bit more back than what is stated on the MBS.


With my PHI - I am looking at - out of pocket expenses for the Surgeon - incl. - some cost for initial and follow up visits, as well as the surgery, and anesthetist costs.

Hope this helps!

I work for a specialist who is with the "no gap" scheme.... which means we get an "extra" 10% (roughly) more than the Medicare Schedule. We submit the patients account into their private fund and get paid from the fund (they then claim from medicare). The patient is not out of pocket.
If my boss decided not to be in the "no gap" scheme, we would add a "gap payment" on top of what medicare and your private fund rebate (medicare schedule).....
for example

Doctor in No gap scheme
Medicare schedule amount - $1000
Medicare will pay doctor $750 (75%)
Private fund will pay doctor $250 (25%)

If the doctor is not in gap scheme

Doctor charges $1500 for procedure
Medicare will pay doctor $750 (75%)
Private fund will pay doctor $250 (25%)
=$1000
Patients gap payment is $500.....

Because the sleeve item number 30511 and the medicare schedule fee is $802.90
Medicare will pay $ $602.20 and private fund will cover the rest up to $802.90.

So the doctor only gets $802.90 for this procedure...... they do not think it is enough... so they add a gap on top of the schedule fee..... ie: the doctor charges $4000 for the procedure.... your gap will be $3197.10.

I hope that explains it.... I really doubt you will get a surgeon to do it for only the medicare schedule......

I agree that the medicare scheduled fee is digustingly low, if you were a surgeon would you want undertake a couple of hours of complex surgery for a measly $800? I sure wouldn't. Medicare should raise the scheduled fee so more surgeon's may actually participate in the No Gap scheme. Given that if we loose weight we would be less of a burden on the Public health system? Kinda reminds me of when I was pregnant with my son and went to see an obstetrician and he charged me $500 "file management" fee. And his receptionist commented to me when she saw my shock at this bill. Cause a heap of obstetrician's have retired they can charge what they like. mmmmmmmmmmm was not impressed especially when the obstetrician could not even bother to look at file my before I went to see him and couldn't remember my name and asked me the same questions every visit. He sure wasn't doing anything for his file management fee! And I only got back $60 of that from medicare.

I emailed the doc and it looks like it will be $3500 out of pocket.

I am happy with that, though there are dietician fee's as well.

:)

I am just about to sign up with private health insurance now and in 12 months time I will be able to get my sleeve

The first appointment is $140 so I might make the appointment soon to get the ball rolling. I am sure there is still a fair amount of things that have to be done.

Hi Amanda

I'm waiting out my PHI too - got mine back in December. It helps if you pace things out so that you always feel like something IS going to happen - see your surgeon, then space out your dietician visits etc so that every few months there's something going on.
Cheers

Just a quick question on this, I too am waiting for my PHI to kick in on March. I was thinking of seeing the surgeon in December so all my appointments are out of the way so to speak and I can book in for the surgery as soon as March 23rd comes around.
How long does it take from the first appointment to the last appointment before surgery? and how many appointments are there usually? I thought it was 2 with your surgeon and one with a dietician? Is there another extra appointment with a psych aswell??? Does this all mean I should bring forward my initial consultation to maybe November this year???
Oh bother now Im confused!!!

Depends on your surgeon. I've heard of people having to see: dietician, psychologist, respiratory specialist, physiotherapist. Others might be able to add more.

Your referral lasts for 12 months from your GP... so you can go anytime to see the surgeon to discuss your surgery.... then he/she will be able to work out when to return closer to your private health insurance kicking in, to time in close to when your 12 months is up...... each surgeon will be different/booked out for longer etc....

Although waiting out the 12 months seems like an eternity, there is plenty to do in that time to ensure that you are being kept busy. While each surgeon is different, my surgeon requires (at least one) consultations with the following:
- dietician
- psychologist
- personal trainer
As well as blood tests, and follow up tests if these are required (not for me, thankfully).
Of course you are able to get the ball rolling well in advance - there is no reason why you couldn't see your surgeon and organise any preliminary appointments during your waiting period, and then schedule surgery in as soon as the waiting period is up.

In regards to out of pocket expenses, it is really amazing how much these can vary from one surgeon to the next. Also the anesthetist bills can vary considerably, so worth considering this in your out of pocket total. And any specialists you have to see (dietician etc). At least having 12 months to wait can give you a chance to save a little ;)

Best of luck, Carah

realme wrote:

Just a quick question on this, I too am waiting for my PHI to kick in on March. I was thinking of seeing the surgeon in December so all my appointments are out of the way so to speak and I can book in for the surgery as soon as March 23rd comes around.
How long does it take from the first appointment to the last appointment before surgery? and how many appointments are there usually? I thought it was 2 with your surgeon and one with a dietician? Is there another extra appointment with a psych aswell??? Does this all mean I should bring forward my initial consultation to maybe November this year???
Oh bother now Im confused!!!

I wouldn't leave it too late to see the surgeon, depends on his waiting list.
The surgeon here is getting so much business his waiting list is getting longer and you are now waiting up to 4 months just for surgery.

I think it depends on the surgeon how many times you see him, I only seen my surgeon once before surgery, but I did initially see his bariatic nurse which is protocol here, you have to go to a seminar and see the nurse before you can get an appointment with the surgeon.

Good luck with your journey.

AmandaJ wrote:

The first appointment is $140 so I might make the appointment soon to get the ball rolling. I am sure there is still a fair amount of things that have to be done.

I have just paid for my daughters op which she is having in 3 weeks.She has had to wait the 12 months for PHI too. She saw her surgeon in March & booked the date for her op then. Lucky, as his fees have gone up since then.

So, it wont hurt to see your surgeon early on, book the date (and the cost).

Thats great news everyone, thanks for the info. Will call dr next week and start the ball rolling! (Im happy!!!)

mapmar wrote:

I work for a specialist who is with the "no gap" scheme.... 



 

Hi there mapmar,

I would love to find out who you work for?

I also live in Perth


Thanks so much for your time!!