No Gap, Known Gap, or more?

There are advantages and disadvantages for each approach.

Accepting a no-gap fee for example, delivers the fastest, and easiest claiming process, with lower friction to the patient, and delivers a smooth process that may better suit the principle surgeon’s preferences.

Known-gap charges, even when supported by the principal surgeon, needs to balance the overall out-of-pockets for the patient with the relatively more complex workflow for obtaining informed financial consent and planning around pre-payments to achieve reasonable settlement success.

Charging more than the known-gap amount means a complex informed financial consent, providing detailed fee estimates, and invoicing that requires careful follow-up for non-payments.

Billing Options :

1. Making a No-Gap Claim - The fee is the calculated MBS amount of the surgery x 1/5 x the fund multiple (which is between 1.4x and 1.52x)
1. Advantages - no need for informed financial consent, patient has no out-of-pockets, rapid payment cycle (can be quick as within 24 hours to settlement)
2. Disadvantages - lower fee than if asking for an out-of-pocket
3. Considerations - surgeons may charge at the no-gap rate, have an out-of-pocket to the known-gap rate, or charge beyond the known-gap rate. Assistants would usually need to have a discussion with the surgeon and probably gauge the appropriate amount to charge to remain consistent with the surgeons’ fee structures.
2. Making a Known-gap Claim - using the same fee calculations, the rebated amount is slightly less from the health funds ( between 1.37-1.50x) and the patient is billed an out-of-pocket amount no more than $500.
1. Advantages - higher remuneration
2. Disadvantages - generally, the out-of-pocket amount needs to be invoiced and payment received prior to the procedure for payment success. Invoicing after the surgery has been performed has a significant risk of non-payment.
1. Informed Financial Consent must be obtained
2. Invoicing and receipt functions should be completed in advance of the procedure date ( generally allowing at least 3-5 days before surgery )
3. A balanced judgement of how much out-of-pocket needs to be balanced between the out-of-pockets charged by the surgeon and anaesthetist, as well as hospital excess as the additional amounts escalate rapidly for the patient. Early financial consent is a must to ensure good relationships with surgeons and patients!
3. Invoicing the Patient the total amount - some surgeons use the AMA rates, or their own rates unrelated of the health fund fee structures - and some, though not all, support their surgical assistants charging an amount generally still expected to be a ratio of their fees (commonly still the 1/5 amount).
1. To ensure payment, typically, invoicing patients in advance, (taking a full prepayment) has the highest chance of payment - the higher the fee amount, the more critical this is.
2. However surgeons or patients may have different expectations for when to issue invoices - including only releasing invoices after services are performed.
3. Informed Consent prior is required, including an estimate of the out-of-pocket. You should be familiar with the general understanding of Prior Informed Consent which has components for
1. timeliness (not on the day of the procedure, and typically at least a few days before is considered neccesary) and
2. specificity - (if charging beyond the known-gap rates, you should provide a fee estimate in total, as well as the amount that is rebatable by Medicare and the Health Funds - the MBS rate),
3. The patient pays the entire amount and submits your receipt to health funds to receive the rebate (up to the MBS amount).
4. Billing costs for this type of invoicing is more costly - upwards of 7% may be required to successfully complete all the informed consent, fee estimate, pre-payment and release of funds functions, as well as refund functions for when procedures are cancelled, postponed or changed.