Anaesthesia fees and gaps
Specialist anaesthetic services attract a fee separate to those charged by the hospital and other doctors caring for you. The fee is based on guidance from the Australian Medical Association (AMA) and the Australian Society of Anaesthetists (ASA) and is dependent on factors including the length and complexity of the anaesthetic. These fees are set as a suggested maximum rate. Generally speaking, your fee from North Shore Anaesthetics will be less than the AMA suggested fee.
You will almost always be able to claim a rebate for a portion of your anaesthetic fee from Medicare and your private health insurance fund. Often there is an associated out-of-pocket expense commonly referred to as the ‘gap’. The size of this ‘gap’ varies and depends mostly on your fund and occasionally your level of cover. Having ‘top cover’ with a fund generally means you have access to a greater number of procedures but does not alter the ‘gap’ payed to doctors.
In Australia Health Funds fall into 2 broad categories which are explained below
- Known Gap Funds – the majority of funds
- No Gap funds – the minority of funds
Known Gap Funds – The majority of health funds in Australia allow for ‘co-payments’ as part of a ‘known gap’ product. This allows doctors to charge a limited ‘gap’ that will not reduce the overall rebate to the doctors, and also provides patients with the knowledge that their out of pocket expenses will be capped. Anaesthetists at North Shore Anaesthetics have individually and independently decided to use ‘co-payments’ where possible. This means your total out of pocket expense will be up to a maximum of $500. Occasionally, if your surgery is long or complex your ‘gap’ may be larger than $500 but if this is the case you will be notified. We suggest that you confirm that your fund accepts co-payments and that your level of cover allows this.
No Gap Funds – Unfortunately, there are some health funds that do not participate in the above scheme. These are termed ‘No Gap’ health funds. In this case you will be responsible for payment of the entire anaesthetic fee and will need to claim the rebate back from your fund. While the total anaesthetic fee will be equivalent to that of a ‘co-payment’ or ‘known gap’ fund, your out of pocket expense will be higher. This occurs because when a doctor charges a ‘gap’ the rebate to the doctor from the fund is reduced. The difference is then passed on to the patient.
Finally, generally speaking, if there is no surgical ‘gap’ there will not be an anaesthetic ‘gap’. If this is not the case, you will be notified.
For more information regarding health funds, doctors’ fees and ‘gaps’ please visit: