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Price difference (insured vs uninsured)

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Price difference (insured vs uninsured)
« on: February 26, 2016, 09:39:07 PM »
Wondering if anyone is able to help me with how much the price difference is for insured vs uninsured for gyno surgery?
What do the healthfunds cover/what medical item numbers?

Linkback: https://www.gynecomastia.org/smf/index.php?topic=31567.0


Offline rajek

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Re: Price difference (insured vs uninsured)
« Reply #1 on: May 08, 2016, 08:20:30 AM »
The variation in private health funds and levels has two things you need to be aware of: 
  • Hospital cover - this will determine whether you are covered for a hospital stay, to what level hospital and how much your excess is. Generally most big funds have arrangements with high-quality hospitals. 

  • Coverage of the surgery - most levels of cover will pay on whatever medicare pays. If you have super basic cover or extras ONLY, it's unlikely your fund will pay towards the surgery. 

Keep in mind that the level of payment for the surgery will not change no matter how good your fund is

Medicare sets a 'scheduled fee' for every item number. Let's say you're getting your appendix out. Medicare says (for example) that the 'scheduled fee' is $900. Medicare pays two thirds ($600) of the scheduled fee. Private health funds pay the remaining third ($300). Most surgeons for almost every surgery under the sun (especially plastics) will charge dramatically in excess of the 'scheduled fee', which they are entitled to do. So the surgeon who takes out your appendix might charge you $2,000. This means only $900 (between Medicare and your fund) is recovered by you and you have a $1,100 "gap". 

Bilateral male mastectomy with lipo has a scheduled fee around $1,100. Can't remember exactly how much. 

Yes, it's all as ridiculous as it sounds. I hope that helps. 

Insured by tricare - Who to go to? San Diego

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