Health funds do cover specialist doctors' fees under certain conditions.
The primary condition is that the consultation or treatment with the specialist must take place as part of your in-patient treatment after you have been formally admitted to hospital. Specialists' fees are not covered in cases where consultations take place as an out-patient, without being admitted to hospital. This includes consultations with obstetricians and gynaecologists for pregnancy, prior to being admitted for birth.
Secondly, you must be covered under your health insurance policy for the procedure you're seeing the specialist about. Keep in mind that not all health insurance policies cover all procedures, so you should know what you're covered for and what you don't have cover for.
Finally, in order for your health fund to pay your specialist's fees, the hospital you are receiving treatment at and the doctor you are receiving treatment from, must have agreements with your health fund.
If your doctor does not have an agreement with your health fund, there is a chance that you may be required to pay a gap to cover the difference between the fee your doctor charges and the amount your health fund will pay for.
The Private Patients Hospital Charter states:
In certain circumstances, you may be referred by your general practitioner to a specialist clinic at a public hospital. If the clinic provides public and private services, you are entitled to be seen by a hospital appointed specialist, free of charge as a public patient. If your general practitioner refers you to a specialist who has a private practice in rooms at a public hospital or a private hospital, you are not an admitted patient of the hospital and will only receive 85 per cent of the MBS fee from Medicare. You will also not be able to claim any amount from your health insurer because the law does not permit health insurers to provide any benefits for consultations and diagnostic services that do not normally require hospital treatment.
Before you undergo any treatment, be sure to ask questions. Ask your doctor if they have an agreement with your health fund, and how much they charge for their services. This is called informed financial consent and it is your right to know. If your doctor does not have an agreement with your health fund and there is a high gap to be paid, contact your health fund and request a list of doctors who do have agreements with them whom you could consult with.
