How much will my surgery cost? 

If you’re likely to need surgery this year, you could be in for a long wait. Although your surgery will be free under Medicare in the public health system, there may be a lengthy wait for non-urgent procedures. Of course, if you have health insurance, you can be seen quicker as a private patient, but that doesn’t necessarily mean your surgery will be free. Depending on your policy, and the doctors and hospital involved, you could have to pay an excess, co-payments and out-of-pocket fees (otherwise known as Gaps). Here’s how to find out how much your surgery will cost. 

Get a breakdown of costs 

The first step is to get a breakdown of costs from your specialist. Make sure they include the Medicare Benefits Schedule (MBS) numbers for the procedures and the fees of everyone involved (such as anaesthetists and assistant surgeons). This quote will tell you what out-of-pocket fees you’ll need to pay for each person involved. Make sure you tell the surgeon your insurer’s details, as the Gap could be different depending on your insurer – for example, the surgeon may have a no-Gap or known-Gap arrangement with that insurer. 

Why do I have to pay a Gap? 

Next, visit the Medical Costs Finder website to compare those Gaps with the national average. If your surgeon is charging a higher Gap than average, you can call other surgeons  in your area and ask how much they charge for that procedure (you’ll need to quote the MBS numbers).  

Check your policy 

Look closely at your policy and make sure your procedure falls under one of the clinical categories (types of treatments) covered. If you aren’t sure, call or email your insurer for confirmation that you’re covered, quoting the MBS number.  

Then, to work out your costs, find out: 

• Does your policy have an excess? If so how much is it? 

• Are there co-payments on your policy (an amount you agree to pay per day for your hospital visit)? Ask your surgeon approximately how long you’ll need to stay in hospital, so you can calculate your co-payments.  

• Does your insurer have agreements with the hospital where your procedure will likely take place, so you can avoid a Hospital Gap? (Note: there isn’t a Hospital Gap if you’re a private patient in a public hospital.) 

• Does your insurer have a no-Gap or known-Gap agreement with your surgeon(s)? Many insurers have online search functions so you can check – if not, ask your insurer.  

How do I avoid a large Gap?

Should I change health insurance to save money on my surgery? 

If you’re facing a large Gap, it could be worth changing policies to an insurer which has a no-Gap or known-Gap agreement with your surgeon. You should only do this if you have already served the waiting periods on your existing policy, and you’re changing to a policy at the same (or lower) level of cover – otherwise, you’ll have to re-serve waiting periods, which means it’ll be 12 months (for a pre-existing condition) until you can claim. It’s a good idea to get written confirmation from a prospective insurer that they will cover your procedure before you switch policies. 

How do I switch insurers?

Remember, Medical Gaps aren’t determined by your policy, they’re determined by the surgeon’s fees. So if you’re facing a large out-of-pocket fee for a surgery that you need relatively quickly, it may be easier to find a new surgeon – and a new hospital, if there’s a Hospital Gap. 

What is a Hospital Gap?

What is a Medical Gap?

If you do want to look for a new policy, you can visit the healthslips.com.au calculator to compare every policy in Australia for free, in minutes. Our calculator has no commercial bias, and we aren’t selling insurance, so there’s no pressure to buy. Best of all, we provide free open access – which means you don’t have to share your contact details. Try our calculator to compare your current policy with what’s available, or search for a new policy.  

healthslips.com.au does not provide general or personalised advice. Your particular circumstances are likely to impact the accuracy, completeness and relevance of the information or results. Take this into account before making a decision and talk to an expert for financial advice.  

Trudie McConnochie

Writer and Researcher

Knowledge is power – that’s the guiding principle behind everything Trudie writes, and it’s a philosophy she brings to her work at healthslips.com.au. By breaking down complex information into easy-to-understand blogs and stories, she aims to empower Australians to make the best choices and an informed decision around private health insurance.

Trudie understands firsthand some of the complexity of private health insurance having moved to Australia from New Zealand and having to navigate a vastly different public healthcare system and health insurance structure.

Trudie holds a Bachelor of Communication Studies (journalism major) from the Auckland University of Technology.

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