One in three Australians are delaying or cancelling non-GP specialist appointments due to costs, according to the private insurance peak.
A new report commissioned by Private Healthcare Australia alleges that up to 30% of patients are being charged “frequently illegal” administration or booking fees for non-GP specialist appointments, hearkening back to previously debunked figures.
PHA represents Australia’s private health insurance sector and has long argued that non-GP specialist fees are driving healthcare costs.
The report, which was prepared by strategy and policy firm Mandala, looked at survey responses from 4000 Australians, of which 2300 had recently been referred to a non-GP specialist doctor.
One in two respondents said they did not know the fee for their specialist appointment before attending, around 40% said they received a bill they were not expecting and one in five said they were asked to pay a non-refundable deposit before their appointment.
A finding that will stick out to many doctors, though, is that 29% of respondents said they had been charged “admin” or “booking” fees, which the report said “avoids the requirements under contractual obligations to charge no-gap or a known gap”.
PHA CEO Dr Rachel David told The Medical Republic that patients were often penalised on multiple fronts when this happened, because the full amount that they pay will not be reflected in their safety net spend.
“We did some quite extensive focus groups, and the sort of things that came up were ‘I was charged a non-refundable deposit and then I was told I couldn’t claim it for Medicare’ … or they’re just saying, ‘well I was given this extra charge and told that I couldn’t claim it back from Medicare’,” she said.
“Our position on that is that if a Medicare benefit is payable, splitting the bill is illegal.
“Anyone who does that should be held accountable for it. There should be a way of finding and prosecuting people who are gaming the system in that way.”
While this represents a slightly different situation, it’s worth noting that claims doctors are rorting the system by billing inappropriate administrative fees have been tested before.
To this end, an independent review of Medicare integrity completed by Dr Pradeep Philip in April of 2023 found that there were no widespread trends of doctors committing fraud.
Australian Society of Anaesthetists president Dr Vida Viliunas said today that informed financial consent was already a routine part of practice for non-GP specialists.
“According to this survey, anaesthetists report that many patients do not fully understand what their private health insurance will or will not cover, an issue outside the control of anaesthetists, whose focus remains on patient care,” Dr Viliunas said.
“Importantly, anaesthetists report actively engaging with patients to waive or reduce fees where appropriate, taking into account financial hardship and patient circumstance, while maintaining a strong awareness of the impact that out-of-pocket costs have on patients in both planned and unplanned care settings.”
The PHA is calling for four key reform actions: mandatory entries on the Medical Costs Finder, improving the regional specialists supply, encouraging scope of practice reform and fixing billing practices; the last of which includes addressing booking or admin fees.
AMA president Dr Danielle McMullen told The Medical Republic that reforms in these areas were already underway.
While the PHA’s asks around greater fee transparency were “reasonable”, Dr McMullen pointed out that doctors have multiple different fees for the same procedure in different scenarios.
“I think most of the general public would be pretty shocked to know that surgeons, for example, may have to have dozens of different fees ready in their books for the same procedure at the same hospital,” she said.
“But where the patient has a different insurer, that doctor has to charge a different fee to be able to no-gap that patient. Maintaining those different fees is a real administrative burden.”
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The medical association is also calling for a private health system authority to regulate the design of the private health system and ensure it is delivering value to patients.
It’s a move backed by the Australian Society of Ophthalmologists, which said it had “critical concerns” about private insurers.
“The fox is in the hen house, and nobody seems to care,” society president Dr Peter Sumich said.
“Private health insurers are laws unto themselves, wheeling and dealing and jumping through loopholes on their way to $2 billion profits a year.
“The lack of regulatory oversight in private health insurer contracting poses real risks to patient care and threatens the clinical independence that is essential for delivering optimal outcomes in eye health.”
