Secret information shows the chance of incurring them is twice as high as the government claims.
We can reveal that in Australia’s third largest health fund, HCF, patients who need ear, nose and throat, orthopedic and oral surgery are more likely to face a gap.
And the chances of incurring a gap fee are highest in the ACT, Western Australia and the Northern Territory but health fund members in NSW have an above average chance of being slugged with a charge.
South Australians are least likely to pay gap fees with Victoria and Tasmania having a lower than average proportion of gaps.
News Ltd revealed last year some cancer patients had gap fees of over $30,000 not covered by Medicare or their Health fund and were raiding their superannuation to pay their health bills.
However, official government data from the Private Health Insurance Administration Council indicates only 11. 6 per cent of medical services paid for by health funds have a gap.
PHIAC reported that the average gap fee was $176 in March this year.
But previously secret data provided by health fund HCF shows almost one in four health fund members will face a gap fee when they use a hospital, twice as many as the government claims.
The reason HCF data shows more people face a gap is that when PHIAC counts gap fees it counts individual services such a pathology tests or a surgeon’s fee.
HCF gives a more realistic picture because it tallies up the total gap fees associated with a total hospital episode which includes multiple services.
The true extent of gap payments across the health insurance industry is likely to be even larger because HCF has the lowest proportion of medical services with a gap in the industry.
“Medical gaps are an area of often unexpected costs and are of great concern to our members,” HCF Managing Director Shaun Larkin said.
“Privately insured patients need to ask their doctor if they provide no-gap services and, if not, why they are charging a higher cost,” Mr Larkin said.
Consumer Health Forum chief Carol Bennett said there was a “very strong experience of people having to meet out of pocket costs” when they used their health insurance.
Australia had the fifth highest out of pocket costs for health in the world, she said.