How To Understand Doctors Bills With Medicare and Private Health Insurance

Australia has a great medical care system called Medicare which is one of the best public health care systems in the world. However, there are some limitations. Not all health services are covered under Medicare, private health insurance is still required. Plus, doctors are free to charge what they want even with the Medicare subsidy. 

Luckily for Aussies, Billy Explores is here to tell the difference between Medicare and public health insurance, plus how doctors fees fit into that (this includes dental care, and that of course means doing a dental health insurance comparison through Billy Explores)!


In Australia, doctors can charge whatever they want for their services. Fees vary because doctors have to think about their own costs when providing services and have different ideas about what they should get for their time and skill. You have the right to ask for a rough estimate of the cost of a service or treatment before you agree to it. Doctors should be ready to talk about their fees before giving services whenever it is possible to do so. If possible, this information should be given in writing.

There will be times when your doctor won’t be able to get your informed financial consent (IFC) before giving you a service. For example, if you have to be admitted to the hospital because of an emergency. In these situations, you or a person acting on your behalf should get the information as soon as possible.

You can always compare health care providers as well with doctors, don’t forget. So when you’re doing a private health insurance comparison through Billy Explores, remember that you should compare health providers too.


Most services in Australia have an MBS fee set by the Australian government. Procedures that Medicare will pay for will have a “item number” and a fee on the MBS.

  • 75% of the MBS fee for in-hospital treatment as a private patient if you are a private patient.
  • 85% of the MBS fee for care outside of a hospital.

But doctors can charge more than the MBS fee if they want to, and many of them do. If a procedure or service that is part of your treatment is not covered by Medicare, there may be no fee for that MBS item number or no item number for that service. This means that you won’t get any help from Medicare, and your health insurance company probably won’t help you either. 

That’s something similar with Medicare and private health insurance. Of course, Billy Explores says you should still have choice and be able to find whether a private health fund will cover you for specific medical services. This is where you need to start comparing health insurance in Australia through Billy Explores.


Medical care outside of a hospital

Health insurers do not pay any benefits for medical services done outside of a hospital. You can go to your doctor or specialist’s office or get a radiology or pathology test as part of these services. Doctors or other service providers may bill in bulk. This means that the doctor will bill Medicare directly, and you won’t have to pay anything for the service or treatment. If the doctor doesn’t bill in bulk, you pay the difference between what Medicare pays and what the doctor charges.

Care in a hospital

If you are a public patient and go to a public hospital, you shouldn’t have to pay for any medical care. If you decide to go to a public or private hospital as a private patient, each doctor and other health professional who helps you may charge a fee. This can include doctors, surgeons, assistant surgeons, anaesthetists, physiotherapists, pathologists, and radiologists. These fees are on top of any fees the hospital may charge for room and board and other services. Medicare will pay 75% of the MBS fee for each MBS item you get as part of your hospital treatment if you are a private patient. The extra 25% will be paid by your health insurance (if you are eligible for benefits for those items under your health insurance policy). If your doctor charges more than the MBS fee, you may have to pay the extra amount. This difference is called the “gap.” Gap cover schemes Gap cover plans let health insurance companies give their members benefits that cover some or all of the gap. Things to keep in mind: 

  • No doctor is required to take part in an insurer’s gap cover programme. 
  • You should always ask your health insurer and your doctor’s office about your gap cover benefits before you get treated. 
  • If there will be a bill for you to pay, the doctor must tell you before you agree to be treated, if possible.


If your doctor arranges for you to go to a hospital or day surgery as a private patient, the Ombudsman suggests that you ask your doctor or the staff in his or her office the following questions:

  • What are the MBS item numbers for the services that the doctor will do, and how much will each service cost?
  • Does the doctor take part in my health insurance’s gap cover plan, and if so, will the doctor still see me?
  • Will I have to pay anything out of my own pocket, and if so, how much? (You may need to check with your health insurance company to make sure.)
  • Who are the other doctors who will be treating me while I’m in the hospital (like an anesthesiologist or an assistant surgeon), and how can I get an idea of how much they will charge?
  • Will the doctor give me a written estimate of how much the treatment will cost so I can think about it before I agree to it?
  • How is the doctor going to charge me?
  • When do I have to start paying?

Compare Health Insurance In Australia

Still thinking about Medicare vs Private Health Insurance? The best thing you can do is start to compare health insurance in Australia through Billy Explores. We have a wide range of health funds and you can save time and effort and explore potential savings by comparing health insurance through us. All you have to do to get started is click here.