No Gap Agreement

Health insurance companies have agreements with some physicians who have agreed to collect fees up to the threshold of some or all of their patients. But even if a surgeon has a gap agreement with your health fund, it`s up to them to choose to use it for you. If you want to charge the patient a higher fee than the amount of the discount listed in the Health Fund`s fee plan, you may want to consider creating a health fund: a private invoice or a known fault bill (depending on your agreement with the Health Fund in question). We assume that the Royal Australasian College of Surgeons (RACS) has strongly discouraged itself from charging the cost of a-pocket to the patient, while taking advantage of a no gap discount as part of your Health Fund agreement. It is also important to note that while your health fund had an agreement with a particular physician in the past, it is usually up to that doctor to participate in the fund system on a case-by-case basis. It is always a good idea to confirm with your doctor before seeking treatment, if they will participate in the scheme of your specific situation. Let`s go into a little more detail. If you are being treated in a hospital, a “planned fee” is charged, as described in the Medicare Schedule Benefit (MBS) for each Medicare item number. Medicare and private health insurance cover 100% of the planned costs, as well as accommodation and theatre costs, as long as you are being treated in a hospital that has an agreement with your health fund.

Depending on your agreement on the Health Fund, AHSA funds can calculate the spread fee (out of pocket) per item and not by invoice. However, when billing a Known Gap invoice as part of your health fund agreement, we understand that the fee may be rejected or significantly underpaid if you set a higher spread fee than you are allowed to charge under your agreement. Although all insurers have gap agreements, there can be a big difference between what they set their thresholds. Take, for example, the vacuum of a health fund for the surgeon`s costs for a knee replacement, which has an MBS fee of $1318: some health insurance companies have agreements with some hospitals and doctors to reduce your out-of-pocket costs. There are different types of gap coverage schemes, some examples are: When determining an AHSA per point of deficit fee, Gentu will always calculate two potential white amounts, and apply according to the lowest amount. This article describes the difference between the three health fund invoices you can create in Gentu. This gives you a little margin if your doctor is charged above the “no fault” threshold, but not all health insurance companies offer a well-known fault option in their system. The insurer sets a known amount of difference, which is often exactly the same amount as the “No Void” amount.

Usually, if the doctor calculates up to $500 more than the known difference, you pay the difference between the amount of the known difference and the doctor`s expenses. The rest will be paid for by the health funds and Medicare. This usually limits your out-of-pocket cost to a maximum of $500.