As a primary caregiver, doctors are on the front lines everyday with patients.
As such, it’s their duty to ensure that their patients not only get the best care, but also make sure they can make an informed decision about their treatment options.

One pain point for many Australians is health insurance, specifically knowing what is covered by their private health insurance and what their out-of-pocket costs will be. This all boils down to informed patient decisions.

Be clear

Start at the beginning. It’s always easiest to assume that a patient knows nothing about how private health insurance works and which costs will be covered. It’s important to explain to them why people get charged out-of-pocket expenses when they use their private health insurance to pay for treatments.

It’s also a good idea to walk them through exactly what is covered under the Medicare Benefits Schedule (MBS). Break down how Medicare will cover 75% of the MBS fee, with their private health insurance covering a minimum of 25%.

Discuss how “gaps” appear when specialists choose to charge more than the MBS fee and that they will either be out of pocket or will need to speak with their health fund to see if there is gap cover available.

Have empathy and be understanding

While it’s impossible for you to know all of the out-of-pocket costs your patient might face, if you are referring them to a specialist it is your responsibility to make sure they are aware of the out-of-pocket fees they may face before you make the referral. If your patient feels that these costs could be too high, then talk them through any public options available to them.

If you’re unable to give your patient an idea of the costs they may face, then you should provide them with the contact details for the physician who will be providing the services, so they may seek more information prior to their visit.

Provide context

You should also explain to your patient what type of policy covers the treatment they are having. For instance, if you’re referring someone on to a specialist surgeon, you should tell them to check their hospital policy. If you’re referring them on to a physio, then explain to them that this is covered by the extras portion of their policy.

If you’re looking to go above and beyond (and have the time), ask your patient what private health insurance policy they have in order to ensure that they are actually covered for the treatment you’re recommending. While they may have hospital cover, it may be a lower tier of cover that excludes the treatment option you’re suggesting. This could lead to a very negative outcome for your patient.

Be conscious of waiting periods

Ask your patient if they are new to their private health insurance. If, for example, your patient has only recently taken out or upgraded their policy, they may be subject to waiting periods and thus not have the right amount of cover when they actually need it.

And finally, if a patient doesn’t explicitly ask, it’s a good idea to explain to them whether or not you are participating in their private health insurer’s gap scheme.


This article was written by Richard Laycock, an Insurance expert from


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