Health insurance, MBS item numbers: can I get my Abdominoplasty operation covered

In this podcast, I will give you an overview of how Private health insurance works and MBS item numbers.

I perform many operations that have MBS item numbers, including.

1. Post-weight loss body contouring surgery

2. Breast reduction

3. Upper eyelid surgery

4. Gynaecomastia

If you want to have any of these operations, you must know how Private Health insurance and the medicare system work.

 

Welcome to the surgery podcast, this is Dr Bernard Beldholm. I’m a Registered medical practitioner, FRACS, Specialist surgeon and my medical registration number is MED0001186274. The content on this podcast is considered adult content.

This podcast focuses mainly on Post weight loss surgery and surgery post pregnancy. Ranging from

• Abdominoplasty (tummy tuck)

• Belt lipectomy (body lift)

• Fleur de lis abdominoplasty

• Brachioplasty (arm lift)

• Thighplasty (inner thigh lift)

I will also discuss breast surgery in the context of post weight loss and post pregnancy changes.

What is Medicare?

Medicare is the insurance scheme that gives Australian citizens and permanent residents access to healthcare.

Medicare is funded by Australian taxpayers who pay 2% of their taxable income to help cover costs.

If you have surgery or medical care in the Public Health system, you will not be out of pocket for these services.

The majority of the operations that I perform are generally not performed in public hospitals. You will, therefore, need to go to a private hospital.

This means that there will be additional costs to consider and this is where Private health insurance comes in.

The Medicare Benefits Schedule

This is the information that is provided on the Medicare website: https://www.mbsonline.gov.au/

The MBS is a key component of the Medicare system. It lists a range of professional services, and allocates a unique item number to each service, along with a description of the service. In broad terms, the types of services on the MBS include consultation and procedural/therapeutic (including surgical) services, as well as diagnostic services.

Subsidies for services by eligible health professionals take the form of Medicare benefits paid to the patient. The MBS sets out the ‘Schedule fee’ for each service and the rate/s at which the benefit for that service is to be calculated, as well as providing guidance on the clinical and administrative conditions under which benefits can be claimed. The rates of benefits are:

• 100 per cent of the Schedule fee for general practitioner services;

• 85 per cent of the Schedule fee for other out-of-hospital services; and

• 75 per cent of the Schedule fee for in-hospital services for private patients.

The Schedule fee is a fee-for-service set by the Australian Government, and may differ from the provider’s actual fee.

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Medicare does not cover the Private Hospital charges. It will only cover the medical practitioner's costs.

The 'gap payment' or 'out of pocket' cost refers to the difference between the amount the doctor charges, and the amount that is paid by Medicare.

It's important to note that the MBS schedule fees have not kept up with inflation.

A rebate freeze was introduced by the Labor government in 2013 as a temporary savings measure. But it was kept in place and extended by the Coalition government until 2018. Even when the freeze was lifted, the annual rebate increase has never risen above inflation.

All other costs of running a practice have increased significantly over the last decade. So, in real terms, Medicare is paying significantly less than it did 10 years ago.

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The costs of your operation will depend on a number of factors.

1. Anaesthetist fee

2. Surgeon fee

3. Assistant fee

4. Private Hospital Costs

If you do not have private health insurance, then you will need to pay the full charge of the hospital.

You will get 75% of the scheduled fee back for the anaesthetist and surgeon fee.

If you have private insurance and it covers your operation, then your hospital stay will be covered, and you will get a minimum of 100% of the scheduled fee from your private health.

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I will go through an example to illustrate these costs for you. Note that the figures I use are only for illustrative purposes, not real. Every patient is unique and the costs will vary.

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Lets have a look at an Abdominoplasty post weight loss.

30177

Lipectomy, excision of skin and subcutaneous tissue associated with redundant abdominal skin and fat that is a direct consequence of significant weight loss, in conjunction with a radical abdominoplasty, with or without repair of musculoaponeurotic layer and transposition of umbilicus

(a) there is intertrigo or another skin condition that risks loss of skin integrity and has failed 3 months of conventional (or non-surgical) treatment; and

(b) the redundant skin and fat interferes with the activities of daily living; and

(c) the weight has been stable for at least 6 months following significant weight loss prior to the lipectomy

(H)

(Anaes.) (Assist.)

Fee: $1,084.90 Benefit: 75% = $813.70

 

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This operation takes around 4 hours and the usual hospital stay is anywhere from 2 days to 7 days.

The Hospital will charge at least 10,000 for the operation and then at least 1200 per day of hospital stay.

Lets say the hospital cost is $15,000

The anaesthetist will charge around $4000

The surgeon fee will be around $12,000

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If you don’t have Private insurance then you will need to pay;

Hospital costs - 15,000

Anaesthetist - 4000 you should get a few hundred dollars back . The Anaesthetist MBS item numbers are very different from above, they depend on your health conditions and anaesthetic units.

Surgeon fee - you will get 75% back of the scheduled fee Benefit: 75% = $813.70

Total fee approximately: $29,686

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If you have private health insurance that covers your operation then your cost would be:

Private Hospital costs $0 note however that a lot of private health insurers have an excess. usually around $500.

Your private health insurance has to pay you a minimum of 100% of the MBS scheduled fee.

Anaesthetist cost

Surgeon costs Minimum benefit paid back Fee: $1,084.90

The total costs for the operation would be around:

$14215.10

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I hope this helps give you an overview of the system and what to expect.

 

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for the comments - QUESTIONS ONLY - NO TESTIMONIALS IN COMMENTS DUE TO AHPRA GUIDELINES.

From 1st July 2023 a GP Referral will be required for all procedures.

Call us on: (02) 4934-5700 or book online: https://beldholm.com.au/book-online/

I’m based in Newcastle & the Hunter Valley in Australia

Hunter Valley Office

30 Belmore Rd
Lorn NSW 2320

 

Newcastle Office

H+ Consulting Suites
Cooks Hill Healthcare Hub
Suite 3, 235 Darby Street
Cooks Hill, New South Wales, 2300

 

Disclaimer

Surgery is a serious decision.

You can find more information about risks & recovery on my website:

https://beldholm.com.au/about/disclaimer/

All Surgery is performed by me Dr Bernard Beldholm my medical registration number is MED0001186274 and my qualifications area

M.B.B.S B.Sc (Med) FRACS,

I’m a Registered medical practitioner and specialist surgeon (specialist registration in Surgery – general surgery).

The content on this podcast is considered Adult content. Individual results may vary. All surgery carries risks. You should seek a second opinion before proceeding. The opinions that are expressed on this podcast are those of Dr Bernard Beldholm & these opinions may differ from other doctors’ opinions.

The information provided on and through this podcast is not medical advice and should not be relied on. It is “best efforts” and for general information only. Do not use this podcast as a substitute for medical advice or self or other diagnosis.

Any surgical or invasive procedure carries risks. Before proceeding, you should seek a second opinion from a qualified health practitioner. Results, recovery & potential complications will vary for each individual patient. Photos & videos featured are not a guarantee that your results will be the same & do not guarantee a particular surgical outcome. Content on our Instagram page & other social media pages is published with the consent of our patients. The content featured is general in nature and does not constitute medical advice. Immediate post-op results may differ from the final result.