Going to Hospital

We know surprises are the last thing anyone wants when they are being treated in hospital.

Doctors’ Health Fund provides a benefit where your treatment is not excluded under your hospital cover and complies with the Claiming Terms and Conditions, such as serving the relevant waiting periods.

There are three different categories for services under your cover:

• Included – access to private rooms at all our contracted hospital and medical bills

• Restricted – benefits for hospital costs equivalent to a shared room in a public hospital an medical bills; and

• Excluded – no benefit

If you have joined Doctors’ Health Fund in the last 12 months, whether you’ve come from another health fund or if you had been previously uninsured, you may need to serve waiting periods before accessing any benefits for services under your hospital cover.

What does included, restricted, excluded mean when we are talking about services?

Included – this is the most comprehensive benefit we offer, providing you with access to one of the largest networks of contracted private hospitals. You will have the freedom to choose single or shared rooms, your choice of doctor and more. You will also be eligible to access benefits towards your medical bills.

Restricted – sometimes referred to as minimum benefits, we will provide a limited benefit for these treatments. Whilst you can be treated in any hospital, the benefit available is equivalent to a shared room in a public hospital. If receiving a private room, or treatment in a private hospital, you may have to make a significant contribution to the hospital bills. You will also be eligible to access benefits towards your medical bills.

Excluded – when a service is excluded, there is no benefit entitlement. This means you will be responsible for the payment of all medical and hospital bills, which could run into the thousands. You should discuss treatment options with your clinical team, such as being treated as a public patient.

Want to check the benefit entitlements under your hospital cover? Login to our member portal.

Waiting periods

In order to be eligible for the benefit entitlement under your hospital cover, you must first serve any waiting periods that apply. Waiting periods apply to what excess you will pay, your level of hospital benefit entitlement and your level of medical benefit entitlement.

The waiting periods are:

• None for accidents
• 1 day for ambulance
• 2 month waiting period on psychiatric services when getting cover for the first time
• None on psychiatric services when upgrading cover. Waiting period can be waived only once a lifetime.
• 2 months for rehabilitation and palliative care, and all other treatments
• 12 months for pre-existing conditions
• 12 months for obstetrics

There is usually no waiting period for treatment for accidents.

These waiting periods apply when someone purchases a hospital cover with Doctors’ Health Fund that has better benefits and conditions than available under their previous hospital cover (or they previously had no hospital cover).

If this is the first time you have purchased health insurance, you will receive no benefit for any treatments during the corresponding waiting period.

If you have not held cover for the treatment for more than 12 continuous months, you may not be eligible to access our benefit entitlements for pre-existing conditions and obstetrics.

If you have purchased cover with better benefits and conditions with us, compared with your previous hospital cover from another fund or with us, you will receive a benefit entitlement equivalent to your old hospital cover for any treatments during the corresponding waiting period.

Once the waiting periods have been served, you will be eligible to access our better benefits and conditions under your new hospital cover with us.

Pre-existing conditions

The most important waiting period to understand is the one which applies to pre-existing conditions.

The purpose of this waiting period is to protect our existing members, by ensuring new members contribute to the cost of their care before claiming. Therefore, this only applies to members purchasing private health insurance for the first time or changing to a new hospital cover with us that provides better benefits and conditions compared to their old hospital cover.

Signs or symptoms

Rather than a clinical question about whether the condition was diagnosed prior to purchasing a product with us, the law asks the Doctors’ Health Fund appointed medical practitioner if there were signs or symptoms of the condition in the six months’ prior to purchasing cover with us.

This could include a lump, cough or anything else out of the ordinary that is directly related to the condition being treated, and would have been apparent to you or to a reasonable general practitioner performing the relevant physical examination.

To assist our appointed medical practitioner, if you have a treatment within the first 12 months of purchasing or changing your hospital cover with us, we will ask that you have our pre-existing condition form completed by your regular general practitioner, treating specialist and any other person consulted about the condition.

It is important you have a general practitioner that is not yourself or a family member, to ensure there are objective records of your health and treatments for our appointed medical practitioner to review. This will also ensure medical practitioners comply with the Medical Board of Australia guidelines.

Once all the information has been received, it usually takes us a week to get back to you, so send through the form well before your planned admission.

If you need the pre-existing condition form, please call our expert Member Service Team on 1800 226 126 or email us on info@doctorshealthfund.com.au

The main purpose of private health insurance hospital cover is to contribute toward the cost of healthcare delivered in hospital when a patient elects to receive treatment, that would otherwise be provided in the public system, as a private patient.

Inpatient

To receive the benefit entitlement under your hospital cover, you must receive treatment from a hospital, as an inpatient of that hospital, for the management of a health condition. Here are three key facts that you need to know about being treated in a hospital:

1. Hospital: This is a facility that the Government has declared as a hospital – a list of private hospitals can be found here.
2. Inpatient: Receiving treatment within a hospital setting doesn’t solely amount to being an inpatient. To be deemed an inpatient:
   • the hospital would have you sign a private patient election form
   • you would occupy a bed on the ward or be enrolled in a recognised hospital in the home program
   • newborns would need to be admitted for a clinical purpose, separate to the mother, such as neonatal intensive care
   • the treatment must be recognised as requiring inpatient care under the law (some tumour excisions are not ordinarily recognised as requiring inpatient care)
   • you would not be receiving care in doctor’s rooms or an emergency department
3. Management of a health condition: As a general rule, private health insurance does not include treatments that don’t attract a benefit from Medicare, are not for the management of a health condition, or where the patient is receiving respite or aged care.

If you’re being treated in a public hospital and don’t elect to be a private patient, then you won’t need to worry about whether you are an inpatient, as your treatment is covered by your taxes.

If you’re being treated as a private patient in any hospital, you will need to speak with the hospital about whether you’re an inpatient.

Emergency

Both private and public hospitals can offer  services in an emergency department, but what you have to pay will vary significantly – with no benefit entitlement under your private health insurance in both these instances.

If treated in a public hospital emergency department, you should have nothing to pay – as your taxes cover the cost of providing these services. If you’re subsequently admitted into the hospital, consider what you’ll get for your money if you elect to be treated as a private patient.

Treatment in a private hospital emergency department is quite different, with charges being raised for visiting the hospital and for every test and consultation by a doctor. The hospital may waive some of these costs if subsequently admitted in to the hospital, so talk to the patient liaison officer about this when signing the consent forms.

What health services will I receive as an inpatient?

There is an important distinction between what is a hospital cost and what is a medical cost – according to private health insurance.

Medical services

Treatment administered by a doctor during your stay in hospital is considered a medical cost. There can be several doctors involved in your inpatient care, including:

• doctor on the ward
• surgeon
• assistant to the surgeon
• anaesthetist
• pathologist
• radiologist
• practitioners in training.

As a general rule, Medicare will make a contribution towards these bills and we will also provide a benefit. More than 90% of the time, the contribution by Medicare and Doctors’ Health Fund has meant members have nothing else to pay.

Hospital services and goods

The other aspects of your hospital treatment are considered hospital costs since they are payable to your treating hospital. These costs include:

• hospital accommodation (including private rooms)
• theatre fees (including labour ward)
• intensive care
• drugs, dressings and other consumables
• prostheses (surgically implanted)
• diagnostic tests
• pharmaceuticals
• all nursing and allied health services (such as physiotherapy)
• hospital administration staff
• television
• meals and bed for your visitors
• parking
• telephone calls
• internet.

Although we try to minimise how much you will have to pay for these services, costs related to items not intrinsic to your care, that are deemed exceptional, or that are not included in our contract with the hospital will need to be paid for by you. If you have anything to pay, the hospital will advise you before you are treated.

We minimise your costs by contracting with hospitals. In this instance, we will make a lump sum payment to the hospital which will ordinarily cover the cost of your care, excluding any excess applicable to your hospital cover.

If you’re treated by a hospital that doesn’t have a contract with us, including public hospitals, there is no cap on how much you will have to pay.

Whilst we have a contract with the vast majority of private hospitals, you can always check if your hospital has an agreement with us on our Contracted Hospitals search. 

How much does the Fund pay/how much do I pay?

Medical bills

• Medicare and Doctors’ Health Fund will pay the amount set out in the Medicare Benefits Schedule (MBS).
• Doctors’ charges are often above the MBS – this is where ‘the gap’ occurs, which is the difference between the doctors’ charges and the MBS fee.
• Where the doctor participates in our Known Gap arrangement, we will pay above the MBS fee but you will still have a gap to pay.
• Where the doctor participates in our No Gap arrangements, we will cover the gap for you.
• If you have chosen our Top Cover hospital, we will always pay significantly more – often leaving nothing for you to pay.

Hospital bills

If you're admitted to hospital as a private patient you'll be entitled to a lump sum benefit for the hospital's services, which typically includes:

• accommodation for overnight or same-day stays
• operating theatre, intensive care and labour ward fees
• supplied pharmaceuticals approved by the Pharmaceutical Benefits Scheme (PBS)
• allied services including physiotherapy, occupational therapy and dietetics
• dressings and other consumables
• surgically implanted prostheses (e.g. a cardiac stent) up to the approved benefit in the Government's Prostheses List

If you’re treated at one of our contracted hospitals, in most instances you'll be fully covered for these hospital services.

If treated at a public hospital, or a non-contract hospital, you may have significant out-of-pockets to pay.

If you chose a hospital cover with an excess, you will need to pay this to the hospital too.

Closing the Gap

Gaps that leave you out-of-pocket happen when the hospital or the doctor charges more than the benefit available under your hospital cover.

Hospital

To minimise both the likelihood and amount of gap payable by you for your hospital bills, use one of our contracted hospitals. We have contracts with over 500 private hospitals and day hospitals.

If you’re treated at a public hospital or a non-participating hospital, there may be significant out-of-pockets and we have very limited ability to assist you during your treatment as we have no direct relationship with that hospital.

At all hospitals, we provide benefits for services and goods that are intrinsic to your inpatient care needs. This means there may be some for which we don’t provide a benefit – such as TV rental and newspapers.

These benefits ordinarily cover the use of disposables (items used during your care and subsequently thrown away) and drugs. If you’re treatment includes gaps for these goods, discuss why with your hospital and surgeon.

At participating hospitals, treatments recognised by Medicare that require the implantation of a device (prosthesis), ordinarily have a corresponding prosthesis on the Government’s Prosthesis List which means you should have nothing to pay. If you are advised there will be a gap, discuss why a no-gap prosthesis isn’t being used.

Medical

So long as the service isn’t excluded under your hospital cover, you will receive the Government listed Medicare Benefit Schedule fee – 75% of which is covered by Medicare and 25% by us.

Your doctor may participate in one of our medical gap schedules which aim to minimise the out-of-pockets payable by you.

If you have Prime Choice or Smart Starter hospital cover, your specialist can opt to participate in our AHSA Access Gap Cover medical gap schedule. Since it is up to the doctor to determine what to charge, they can choose on a case-by-case basis whether to participate.

With our unique Top Cover you will have greater peace of mind as it provides benefits equivalent to those recommended by the Australian Medical Association in its list of medical Services and Fees with no requirement for your doctor to enter into any special arrangement with us.

Questions to ask

When you find out that you need inpatient hospital treatment, call or email us to find out:

• your level of cover for the treatment
• any waiting periods left to serve
• whether you have an excess to pay
• if you’re attending a participating hospital
• if your doctor is known to use our AHSA Access Gap Cover schedule (this question is not necessary if you are on Top Cover as your doctor doesn’t need to have an agreement with us in order for us to pay up to the AMA Gap amount)

Ask your specialist:

• (if you are on Smart starter or Prime Choice), ask if they will use our AHSA Access Gap Cover schedule
• about any other costs for outpatient or inpatient services
• about costs associated with prostheses
• for a quote about any likely gap you have to pay:
  • your specialist should disclose the cost and obtain your agreement before your admission to hospital
  • they should also provide advice on fees charged not only by them but also by other specialists or surgeons (such as anaesthetists, assistant surgeons, pathologists and radiologists)
  • if there is a gap, the doctor should get your signed consent (known as Informed Financial Consent) prior to treatment
• for contact details of the other practitioners involved in your treatment if there is uncertainty about whether their services will involve a gap to pay.

Ask the hospital:

• if the diagnosticians used by the hospital will charge a gap
• if you will have to pay for anything and why.

If the costs aren’t affordable, discuss with your specialist alternate:

• hospitals
• anaesthetists/assistants
• prostheses.

Ultimately, if your condition is urgent and the cost of being treated privately is unaffordable you can seek treatment as a public patient at a public hospital.

One of the key benefits of private health insurance is you freedom to choose your doctor.

To make an informed decision when choosing your specialist, it is important you discuss their outcomes with your general practitioner and look into their charges, as part of obtaining a referral.

We recommend checking our doctor search, which lists specialists that have known experience with using our “AHSA Access Gap Cover” medical gap schedule to reduce your out-of-pocket. Please note that specialists opt to participate in this medical gap schedule on a case-by-case basis, so previous participation is not a guarantee that they will opt in for your treatment.

With limitations on what we are allowed to provide a benefit for, it is important to know what doctor bills you can and can’t claim with us. Read more about Claiming Terms and Conditions.

How much do doctors charge?

The fees doctors charge patients for their professional medical services must cover their practice costs. Every private practising medical practitioner incurs a wide range of practice costs in order to provide a high quality service to patients.

The costs of running medical practices vary across the country, and across speciality groups. But every medical practice, be it a sole practitioner or a large corporate practice, incurs the cost of employing administrative and clinical practice staff, general running expenses such as computers, rent, electricity, professional indemnity insurance and in most cases the cost of medical equipment and supplies.

The practice costs must all be met entirely from the fee charged by the doctor for the medical service they provide to patients.

Why is there a gap?

We are not allowed to provide a benefit for treatment you receive as an outpatient (when you are not an inpatient of a hospital). This means you have to pay for the difference between the charge and any Medicare benefit – your out-of-pocket.

AHSA Access Gap Cover doesn’t apply to pathology and radiology services (although these are often fully covered if you are attending one of our participating hospitals), nor does it apply to your excess or any services not included under your cover.

Read more about the gap.

Specialist non-claimable

With benefits confined to those treatments you receive whilst an inpatient of a hospital, there may be a number of other treatments and visits with your doctor that you will pay for but won’t receive a benefit from us.  This would include any pre-operative and post-operative visits with your doctors.

If you incur relatively significant out-of-pocket on these outpatient treatments, you may be eligible for higher benefits from Medicare – which can substantially minimise your out-of-pocket. This is an automated process and the Department of Human Services would automatically pay you these higher benefits.

Informed Financial Consent

If your hospital stay involves any out-of-pocket hospital charges, the hospital (whether private or public) should disclose the cost and obtain your written confirmation of understanding and agreement to proceed with treatment – before your admission.

If your doctors' fees include any out-of-pocket charges, your specialist should disclose the cost and obtain your agreement before your admission to hospital. They should provide advice on fees charged not only by themselves but also by other specialists or surgeons as well as by anaesthetists, assistant surgeons, pathologists and radiologists.

Weeks before

You may be required to attend a Pre-Admission Clinic, up to three weeks prior to your admission. Your doctor, or the hospital, will contact you if they wish you to attend.

The length of appointments will vary but can take up to three hours. It may involve pre-operative tests and discussions about your procedure and recovery with your clinical team.

When attending the clinic, ensure you take along all your original admission forms, any information from your GP, any additional test requests from your doctor, and a list of your medications.

The clinic is considered an outpatient visit. Medicare will reimburse some of the costs of some tests but we aren’t allowed to pay for any of this outpatient medical care.

Day before

FASTING: Generally your doctor or hospital staff will advise you how long before your procedure you should not eat or drink - usually at least six hours prior to your surgery (ask specifically about how much water you can consume).

If fasting instructions are not followed, your procedure may have to be postponed in the interests of your safety.

MEDICATION: If you take any regular medication (including non-prescription medication) you should discuss this with your doctor. You may need specific instructions regarding which medication you should cease and which you should continue. Always take your current medication to hospital.

Hospital admission forms

Most hospitals will send you an admission pack once you’ve booked in. This pack outlines the hospital’s facilities, asks some medical history questions and to supply an emergency contact. It’s important to complete and return this promptly as the hospital needs these details to confirm your cover and process your admission.

To complete these forms, you will need your:

• Doctors’ Health Fund details:
  • membership number
  • product name
  • any applicable excess
  • date of joining
  • date paid to
• Medicare card number
• Health care card/DVA
• Visa/MasterCard/Amex details
• Medications (including non-prescription and any vitamins) – names, doses, frequency

Admission

Even though you’ll be taking timeout while you’re treated and recover, this doesn’t mean the rest of your life does.

It’s important that you make plans about your recovery and work, family and social obligations well before you go to hospital.

Things to consider:

• arranging for time off work, including for rehabilitation
• ask for a medical certificate if you need one
• care for family members and pets you are responsible for
• transportation to and from hospital
• discuss with your emergency contact when your  procedure is scheduled, what’s expected of them and to keep their phone with them in case you or the hospital need to make urgent contact during your admission

Things to pack:

• your Medicare card and your Doctors' Health Fund membership card
• information about your blood type
• your hospital bag for labour (if pregnant)
• your hospital's pre-admission pack (if you received one)
• clothes and toiletries (including slippers, underwear, and clothes to leave in)
• anything relevant to your treatment – like referrals, blood tests, scans, x-rays
• any medication you use
• items to enhance your comfort such as eye masks and earplugs
• money for incidental expenses such as vending machines, café snacks

Post-acute care

If you're assessed during your hospital stay as no longer needing acute care after spending more than 35 days in hospital, you'll be classed as a Nursing Home Type Patient (NHTP). In this case, Doctors’ Health Fund will pay benefits that are much lower than normal hospital benefits and you'll be required to make a personal contribution towards the cost of your care.

Even though you’ll be taking timeout while you’re treated and recover, this doesn’t mean the rest of your life does.

It’s important that you make plans about your recovery and work, family and social obligations well before you go to hospital.

Things to consider:

• arranging for time off work, including for rehabilitation
• ask for a medical certificate if you need one
• care for family members and pets you are responsible for
• transportation to and from hospital
• discuss with your emergency contact when your  procedure is scheduled, what’s expected of them and to keep their phone with them in case you or the hospital need to make urgent contact during your admission

Things to pack:

• your Medicare card and your Doctors' Health Fund membership card
• information about your blood type
• your hospital bag for labour (if pregnant)
• your hospital's pre-admission pack (if you received one)
• clothes and toiletries (including slippers, underwear, and clothes to leave in)
• anything relevant to your treatment – like referrals, blood tests, scans, x-rays
• any medication you use
• items to enhance your comfort such as eye masks and earplugs
• money for incidental expenses such as vending machines, café snacks

Post-acute care

If you're assessed during your hospital stay as no longer needing acute care after spending more than 35 days in hospital, you'll be classed as a Nursing Home Type Patient (NHTP). In this case, Doctors’ Health Fund will pay benefits that are much lower than normal hospital benefits and you'll be required to make a personal contribution towards the cost of your care.

Getting back on track

To get you back to feeling a hundred per cent, it's possible you might need further practitioner consultations after you leave hospital. At the very least, you'll probably need to take time out to rest and recover. We're here to help you get back on your feet and stay well once you've recovered.

Before leaving hospital, we recommend asking your specialist the following questions:

• What medicines will I need during my recovery?
• When can I resume day-to-day activities?
• When is my next appointment?
• What complications might arise and what should I do if this happens?
• Will I need help at home, and how can I organise it?

If you have Extras cover, don't forget to use it if you need ongoing treatment (e.g. physiotherapy).

Depending on your circumstances, you may also be able to take advantage of the following health and wellness programs we offer:

• If you have our Total Extras cover and live with chronic disease, you could access our Health Management Program benefit to support your return to good health.
• If you’ve been diagnosed with knee or hip osteoarthritis, diabetes or heart disease you may be eligible for our 18 week Healthy Weight For Life programs.
• In-home rehabilitation: We work with a number of providers around Australia to provide rehabilitation services for a wide range of conditions and procedures. You can talk to your treating doctor about whether the program might be suitable for you.