The cost of specialist surgical care in Australia is not always straightforward. There are multiple providers involved, and the gap between what Medicare and private health insurance cover and what is actually charged can come as a surprise to patients who have not been through the process before. This page explains how fees are structured so you know what to expect before you proceed.
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Australia has universal health coverage through Medicare, which provides all Australian residents with a rebate for a wide range of medical services. Most orthopaedic consultations and surgical procedures are covered by Medicare item numbers, each with an associated government rebate. Private health insurance supplements this rebate and covers most hospital costs.
The private health system allows patients to choose their surgeon and to access elective surgery in a private hospital. Understanding how fees are structured avoids unexpected costs.
Initial consultation fee: $180 to $280. Subsequent consultation fee: $95 to $200. A Medicare rebate applies to both, reducing the out-of-pocket amount. Please contact the rooms to confirm current fees before your appointment.
All orthopaedic procedures are covered by Medicare item numbers with an associated rebate. The government sets these rebates, and private health insurance funds supplement them by up to 25 per cent. These rebates have not kept pace with inflation since they were established in 1983, and most surgeons charge at AMA (Australian Medical Association) rates, which more accurately reflect the genuine cost of specialist surgical care. The difference between the AMA fee and the combined Medicare and fund rebate is called the GAP.
Mr Balakumar takes a different approach to minimise out-of-pocket costs for patients. Rather than charging a full GAP on surgery, he charges an administrative fee on the day of surgery as the only out-of-pocket expense. This fee is between $200 and $550. After the procedure, his billing department submits the account directly to the health insurance company. Patients in exceptional circumstances, including overseas patients, may need to pay directly.
The anaesthetist charges separately and is not part of Mr Balakumar’s billing. Most anaesthetists charge a gap payment of $250 to $1,000. Your anaesthetist will contact you before surgery to obtain informed financial consent.
The assistant who assists during surgery charges separately. Most surgical assistants charge a gap of $100 to $350.
Hospital costs cover the operating theatre, bed, nursing care and equipment. With private health insurance these are largely covered, subject to your excess and any procedure exclusions in your policy. Check with your insurer before booking surgery.
If an implant is required, the cost is regulated under the Commonwealth Prostheses List. In most cases patients do not pay out of pocket for the implant itself, though this depends on the specific device and your fund. Confirm with your insurer prior to surgery.
All orthopaedic surgeries are covered by Medicare item numbers. These numbers have an associated rebate. The government determines these rebates and the private health insurance companies supplement these rebates by up to 25%.
Unfortunately, these rebates have not changed much since 1983 and have not kept up with inflation, let alone the costs of running a quality practice and the increasing cost of indemnity insurance. The difference between the costs and the rebates has given rise to the GAP. Most surgeons will charge AMA (Australian Medical Association) rates for the services. This is almost three times the Medicare rebate and reflects the true discrepancy
Uninsured patients will require a quote from the hospital and the prosthesis companies. Once again the surgeon’s fees are mainly rebated by Medicare and therefore the patient will not have to pay much out of pocket for their surgeon.
Mr Balakumar is one of a small number of surgeons in Australia with formal training in both paediatric and adult hip surgery. His fellowship at Harvard’s Children’s Hospital in Boston, under some of the world’s leading specialists in hip preservation, gives him a depth of expertise that is difficult to find in a single practice.
His approach is the same whether the patient is 6 months or 65 years old – thorough assessment, honest options, and no pressure toward surgery until the clinical picture clearly supports it.
(03) 9573 9659
