Out of Pocket Expenses

Following the submission of your insurance claim, any out of pocket expenses not covered will need to be paid. If we have your credit card details on file, the outstanding amount will be taken from your credit card. If not, an account will be sent to you in the mail. A copy of your receipt detailing all payments will be forwarded to you along with the finalised account. We will call you to authorise any deduction greater than $500.

St Vincent’s Private Hospital Sydney has reached agreements with most major health funds to meet the cost of some services such as physiotherapy. However, not all funds cover these costs. Please contact your health fund directly to confirm their coverage of these services.

If you have any questions about your account after discharge, please contact our Patient Accounts Department on tel: 02 8382 7406.


Fact Sheet - Out-of-Pocket Expenses for Private Medical Treatments

How are Doctors’ fees set?

The Australian Government sets a fee for every medical service in the Medicare Benefits Schedule (MBS). When you have hospital treatment as a private patient, Medicare will pay 75% of the MBS fee and your private health insurer will pay the remaining 25%.

In Australia, doctors are free to decide how much they charge for their services.

Fees may vary because doctors have to take into account their particular costs in delivering services and what they believe represents a reasonable return for their time and skill.

A doctors ‘gap’ occurs when your specialist, and/or the other doctors involved in your hospital care, charge more than the MBS fee.

If your doctor/s charges a ‘gap’, you are required to pay the difference between the MBS fee and the total charges set by your doctor/s. This cost is often referred to as an ‘out-of-pocket’ cost.   

The hospital has no influence or control over these charges set by your doctor/s.


Informed financial consent?

Within Australia you have the right to ask for an estimate of these charges. This is known as informed financial consent. This provision of information should outline all out-of-pocket expenses a patient may incur by their doctor/s. This information should be provided in writing prior to your hospital admission or treatment.


How can I find out about any gaps before going to hospital?

Before going to hospital as a private patient, you should ask the doctor for an estimate of their fees. You should also ask about any other doctors likely to be involved in your care (e.g. anaesthetist, assistant surgeon) and how to get information about their fees.

Check with your health insurer about how much is likely to be covered by your health insurance policy.

Prior to your hospital admission you may be required to pay a health insurance ‘excess’ payment. This payment can be made at the hospital at the time of your admission. You should also check with your insurance provider about any excess payments related to your hospital stay.


How can I avoid unexpected medical costs?

The Private Health Insurance Ombudsman recommends that you ask about fees before seeing your doctor or at your first visit. Your doctor/s may set their gap fee on a case-by-case basis.


What should I ask?

What MBS item numbers will be used for my anticipated procedure/s

  • What out-of-pocket-costs will I incur

  • A written estimate of these costs

  • When will I have to pay any out of pocket costs

  • What other doctors are likely to be involved in my care (e.g. anaesthetist, assistant surgeon)


What can I do if I cannot afforded the estimated costs

  • You can discuss a payment plan or payment options with your specialist
  • You can discuss alternate treatment options with your specialist or GP

  • You can discuss an alternate specialist referral for a second opinion with your GP

If you feel you cannot afford the referred specialist’s out of pocket costs, it is imperative to remember there are always other options that can be explored. Due to the variation in out of pocket costs across all health facilities in Australia, there is a high probability a similarly experienced specialist is working within your hospital of choice. This specialist may charge no gap or present more a affordable financial solution.

High out of pocket costs do not correlate with improved patient quality outcomes.


What can I do if I receive a bill that was higher than I expected for my procedure?

The Private Health Insurance Ombudsman suggests:

  • Contacting your doctor’s office to discuss the reasons for the variation in charges and why they are more than you expected.

  • If you are unable to negotiate a suitable outcome with your doctor, you may contact the NSW Health Care Complaints Commission (HCCC)


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