Pathology gap fees

Consumers can face large gap payments for pathology, but a public provider may be able to provide a gap-free alternative.
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01.Mind the gap

Pathology gap fees

Since the decrease in Medicare rebates for pathology in the 2009 Federal Budget, there has been a push from private pathology providers to increase the number of people paying an out-of-pocket gap payment.

When your GP requests pathology (for example, a blood test or skin biopsy) for you, this is done through the GP clinic, a “shop-front” collection centre or, if you live in the country, most likely a hospital outpatients department. It’s largely paid for by the federal government through Medicare, which has a “scheduled fee”.

Medicare rebates 85% of this scheduled fee; if your provider accepts this rebate as full payment, they can bulk bill Medicare direct, at no cost to you. If the provider wants more than the rebate, you will receive an account and have an out-of-pocket “gap” to pay. Alternatively, where there’s no Medicare rebate you will be required to pay in full (some public providers do some non-rebatable tests at no charge to the patient).

How big is the gap?

Private providers base their charges on the Australian Medical Association’s (AMA) suggested fees, which on average are almost double the Medicare scheduled fee. Because many people have several pathology tests at once, resulting in a large total gap payment, most private providers do have a cap.

When out-of-pocket gap payments reach $1126 (or $563 for people with a concession card or who come under Family Tax Benefit A), the Medicare Safety Net applies and 80% of gap payments are covered.

Gap-free is all down to your GP

Gap-free pathology is available to everyone in some form.

  • When your GP chooses a public (state government) provider, the service is bulk billed to Medicare – but this option is limited and, therefore, impractical in some areas.
  • When your GP refers you to a private provider, gap-free bulk billing can be requested on the form if you’re a pensioner, Gold Card Veteran or Health Care card holder, nursing home resident or in difficult financial circumstances.

If your GP forgets to do this, private providers usually bulk bill concession card holders anyway. Some GPs request bulk billing for all their patients, and private pathology companies are philosophical about this, especially if the GP bulk bills as well.

How to be bulk billed

Ask your GP to use the bulk-bill option with the pathology provider they use. If your GP won’t do this, ask whether you can use the public provider. You’ll need to attend the public provider’s collection centre if they don’t offer a courier service to the surgery, which may be difficult in some areas.

CHOICE suggests taking the private pathology form from your GP (you can also use this at the public provider), contacting the provider directly to find out the total gap payment – especially if you’re having multiple tests – and making a decision based on the travelling involved to both public and private collection clinics. Be aware, however, that your GP can overrule your decision.



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