Answers for Fees
Frequently Asked Questions
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Q1. What are Dr Nihal’s consultation and surgery fees based upon?
Ans: Dr Nihal is a member of the Australian Medical Association (AMA) and the majority of his fee structure is based upon the recommendations/guidelines of the AMA and has no relationship whatsoever with the Medicare rebate.
Consultation fees from 1st January 2013 : for initial consultation is $190 (Medicare rebate $72.75) and for Review appointment is $90. (Medicare rebate $36.55).
Dr Nihal initial and review consultation would increase annually as per schedule increase in AMA fee , which as in independent of Medicare rebate. Please phone our room to confirm the current fee structure, before booking an appointment.
Regarding operation fees:
The foot and ankle is a complex structure consisting of approximately 26 small bones, 39 joints, 19 muscles/tendons and 107 ligaments. Hence any surgery is bound to be tricky, fiddly, intricate and complex.
Medicare pays a relatively large rebate for fixing fractures of large bones i.e. femur (thigh bone) /tibia (lower leg bone) but pays a much smaller rebate for fixing fractures of small bones such as those in the foot. The amount of Medicare rebate for foot and ankle surgery does not therefore reflect the surgical complexity, duration of operating time, technical operative skills required, as well as the number of post-op visits in the ward and repeated and recurrent review appointments in the private rooms. Post-op reviews are of necessity and more frequent following foot/ankle surgery than reviews following large bones/joints surgery such as hip or knee replacements.
Dr Nihal’s surgery fee also includes an assistant fee. We will give you the approximate cost of the total fee i.e. surgeon fee & assistant fee before the surgery.
Q2. Why we have to pay “Gap” for Surgeons fee?
Ans. Dr Nihal’s and the surgical assistant’s fee for the proposed operation will vary according to the complexity of the procedure. If the procedure is more complex and the rebate from Medicare/Health funds is lower and not proportional to the complexity of the procedure then a higher “gap” amount will be payable by yourself. The majority of Dr Nihal’s fee structures are based upon the standard AMA rate guidelines. Thus foot & ankle operations performed by Dr Nihal will often incur “out of pocket expenses – “gap” payment.
The foot & ankle are complex structures & Dr Nihal’s surgery fees are determined by the followings factors:
- Complexity of the operation
- Duration of operation
- Technical skills involved
- Hospital stay
- Number and length of post-operative follow-ups in the clinic & dressing changes etc
- Rebate from your health funds
Our practice will give you the approximate breakdown of the cost for the proposed operation. It is then your responsibility to ask you health fund as to how much money you will get back. Your health fund and the level of cover you have taken determine this amount.
Operations on smaller bones and joints in the foot and ankle attract smaller rebates, so patients will receive less rebate as compared to patients undergoing hip and knee replacements.
The rebate you will receive from Medicare/Health funds is not determined by Dr Nihal but is pre-determined and set by your health funds/Medicare. This amount does not represent the total surgeon’s fee but is financial assistance to cover part of the surgeon’s fee.
If you feel concerned that this amount is low, then you should raise this issue with Medicare Australia and your health fund as to why the rebate for the surgeon’s fee is lower than the AMA recommendations.
Needless to mention, your health fund & Medicare pay a very substantial amount (mostly in thousands of dollars) to the hospital where the procedure is being carried out. Thus it is very important to understand that your health fund primarily operates to cover the large amount of costs involved in hospitalisation for the proposed surgery. This includes the operating theatre costs, ward admission, nursing care, cost of anaesthetic drugs, surgical implants, plates, screws metal rods, ICU care if needed etc.
Q3: Why I have to pay the full amount? Why can’t you charge a “gap” and the rest you collect from my health funds?
Ans: Some health funds are strictly “No Gap” health funds. These “No Gap” health funds” prevent us from charging you a “Gap” & restrict us to accept their lower surgery fee which in no way reflects the complexity of foot and ankle surgery. Thus if you are a member of the “No Gap Health funds” then you will have to pay the full amount of Dr Nihal’s fees in advance. After the surgery we will give you the receipt to lodge a two-way claim with Medicare/health fund for your rebate. The amount you will get back will again depend on your health fund & your policy cover.
However should you be a member of the “Gap health funds” then for Dr Nihal’s surgery fee, you may be asked to pay the permissible “gap” called the “Known Gap” (depending on the complexity of the case and rebate from your health funds) and the rest we will collect from your health funds. We will inform you in advance regarding this.
Q4. I am confused about “ gap payment”, “ out of pocket expenses”, “known gap” rebate from Medicare and rebate from health funds etc? Please explain.
The “gap payment” is actually the “out of pocket expenses” which you will incur after claiming your rebate from Medicare and your health fund. For example, you had surgery where the surgeon and assistant’s fee was $2500, which you paid in advance. After surgery you lodged a two-way claim to Medicare and our health fund. You received $250 from your health fund and $750 from Medicare thus your out-of-pocket expenses for the surgeon’s fee was $1500. The amount of $1500 is the “gap payment” or “out of pocket expenses”.
About the “ Known gap”: the majority of health funds in Australia are “ Gap Health funds”. These funds allow the surgeon to charge a permissible gap from the patient called a “Known gap”. The remaining balance of surgical fees is collected directly from your health fund after your surgery. If you are a member of the “ Gap Health Funds” then you may be asked to pay the “Known gap” only and the rest we collect from your health funds. However this “Known gap” is not accepted by our practice for the more complex foot and ankle surgery cases but may be permissible for the more straightforward procedures. You will be informed before the scheduled surgery regarding “out of pocket” expenses and the “Known gap” if applicable. We will obtain informed consent from you before the surgery.
Q5: My friend Mr Smith had knee replacement surgery done by surgeon Dr X at Pindara hospital and my other friend Mr Willis had a knee arthroscopy keyhole surgery by surgeon Dr Y at John Flynn Hospital but these surgeons did not ask Mr Smith and Mr Willis for any fees at all. Why are you asking for the full surgery fee or “gap“ fee in advance?
Ans: Dr Nihal is also happy to do knee arthroscopy or knee replacement surgery on you at no cost to you at all! As mentioned previously the Medicare/health funds rebate for small bones in the foot is comparatively small and does not reflect the complexity of the case as well as not taking into consideration the multiple post-op review appointments following foot surgery. The rebate from Medicare/health funds for surgery to large bones i.e. knee arthroscopy, total knee and hip replacement is a reasonable amount so most surgeons do not need to charge you a gap at all. This practice is also happy to provide “no gap” for knee arthroscopy, hip and knee replacement etc.
Q6: We pay a lot of money to health funds every month; the insurance premium goes up regularly as well as the Medicare levy! In spite of this we had to pay a “gap” to the surgeon, “gap” to the anaesthetist etc and the rebate we got from the health funds/Medicare was a very small amount? Is it worth having private health insurance?
Ans. The Medicare rebate is an arrangement between the government and the patient. The Medicare rebate has not increased substantially for many years as compared to the large & ever-increasing costs of running a private practice, inflation and the associated cost of providing quality care to the patients. Medicare/Health funds do not fully cover the surgeon and anaesthetist’s fees. Needless to mention, the surgeon’s and anaesthetist’s fees are only a minor component of the cost for your surgery as compared to the theatre fees, hospital stay, nursing care in the ward, the cost of prostheses, insertion of plates, screws and provision of ICU care if needed. Thus this cost can run into many thousands of dollars, which is fully paid by your health fund/ Medicare. If you do not have private insurance then the amount payable from an uninsured patient for a complex operation may be anywhere from $10,000 – $30,000 upwards!
The health fund rebate again depends on the type of health fund you are a member with since the rebate amount varies between the health funds. The Medicare and health fund rebates you receive are independent & not determined by your treating surgeon.
Should you feel concerned about the level of your Medicare rebate then please write to Medicare Australia, Federal Health Minister or to your local federal MP regarding this.
Q7: Apart from Dr Nihal’s fee, do we have to pay any more costs towards the proposed private surgery?
Ans: Yes. The Anaesthetist’s fee is different and Dr Nihal has no control on the anaesthetist’s fee. My secretary will give you the telephone numbers of the Anaesthetic group and it is your responsibility to contact them and to ask them an estimate anaesthetic cost for your surgery. Most Anaesthetists charge a gap & you will most likely incur out-of-pocket expenses.
If you are privately insured and have full private hospital cover then generally hospital admission, theatre fees, theatre prostheses, metal plates and screws used, nursing care in the ward, meals etc are all covered. You may have to pay the hospital access to your health funds if you have any access on your policy. Please ask the hospital and your health funds regarding this. You may incur small extra expenses for radiology, pathology, pharmacy and the use of newspapers/ internet/ telephone etc. Please ask the hospital reception staff regarding this.
Q8: I want Dr Nihal to fill income protection forms/ air travel insurance cancellation claim/school insurance claim. / Life insurance claim forms etc- Do I have to pay any fee?
Ans: We issue standard medical sickness certificate or a certificate of attendance free of charge to all patients. However other claim forms as mentioned above usually take considerable time to complete and will therefore incur a small fee. Please ask our staff for the current fees for completing these forms.
Q9: Can we see Dr Nihal privately and then he can do operation on me as public patient in public hospital.
Ans: Dr Nihal only provides a private service. Dr Nihal does not have admitting rights in public hospital. If you agree to have surgery by Dr Nihal then this will be carried out in the Private hospital.
Q10: What methods of payment do you accept for consultation/surgery fees?
We accept Visa, MasterCard, EFTPOS or cash. The consultation fee is paid on the day of consultation and the total surgery fee or permissible health funds gap is payable 5-7 days in advance before the surgery date. This can be done over the phone. We do not accept American Express or Diners Club cards.
Q11: Can you tell us in advance on the phone as to how much it will cost to have my surgery?
Unfortunately we cannot tell you the exact costs for the out-of-pocket expenses until Dr Nihal sees you in the clinic and decides which operation and what item numbers are the most appropriate for your case. We are therefore unable to provide you any quote for surgery until after the clinical consultation with Dr Nihal. Once you have decided to proceed with surgery then secretary will provide you with an approximate quote for surgery along with associated costs and approximate rebates from Medicare /health funds.