Health Insurance and your Surgical Fees

How much will I be charged for my operation?

The fee you are charged depends on the length and complexity of your surgery, and is based on the recommendation of the AMA (Australian Medical Association). If you have private health insurance, part of the cost of your operation will be covered. However, you may still have to pay a gap for the medical fees. If you are self funding your operation, you will receive a Medicare rebate which is 75% of the Schedule fee (see below).

How much will Medicare cover?

The Medicare Benefits Schedule is a list of operations which is compiled and updated by the Commonwealth Government. Each operation is allocated an item number and a Schedule fee. It is not a recommended fee, but simply represents the amount that the government is willing to pay. The Medicare rebate is the amount that you can claim back from Medicare, and is 75% of the Schedule fee for operations.

Why is there a gap between the surgeon’s fee and the Medicare rebate?

There are two reasons why there is a gap between the surgeon’s fee and the Medicare rebate:

  • There is a 25% gap between the Medicare rebate and the Schedule fee
  • There is a gap between the Schedule fee and the surgeon’s fee

The Medicare Schedule was established in 1985, and while there has been regular increases in the Medicare Schedule Fee, these Government-determined fees have not increased at the same rate as inflation and the cost of running a practice. This is why most doctors charge more than the Schedule fee, and why the gap continues to increase. The Schedule fee also does not necessarily reflect new, more complex procedures and techniques.

How much is ‘the gap’?

The gap depends on:

  • the operation you are having
  • which health insurance fund you have cover with
  • whether Dr Balendra chooses to use the GapCover arrangement of your health fund

GapCover allows your health fund to cover some of the surgeon’s gap leaving you with a smaller co-payment but restricts the amount the surgeon can charge. Different insurance companies also pay different fees for the same operation.

What does my health insurance cover?

Your health insurance covers the majority of the costs of your operation. Most health funds have agreements with private hospitals. Apart from any excess your policy may have, your health fund covers your hospital costs, including bed fees, theatre fees and the cost of implants. Please contact your health fund directly if you have any questions.

Your health fund covers the 25% gap between the Schedule fee and the Medicare rebate. In some cases, it also covers part of the gap between the Schedule fee and the surgeon’s fee.

Will I be informed of the costs?

Our practice provides informed financial consent before your operation. You are informed of the surgeon’s fee, the item numbers used and the out-of-pocket gap. On the rare occasion, the actual procedure performed (and the associated surgical item numbers) may be different to that quoted for, which can increase or decrease your fees and rebates accordingly.

You will also be given the names and contact numbers for other doctors (anaesthetist and surgical assistant) involved your operation so that you can contact them for an estimate of their fees.

What if I don’t have health insurance?

If you wish to self-fund your operation, you will receive a Medicare rebate which is 75% of the Schedule fee. You will be responsible for the rest of the costs, including the surgeon’s gap, the theatre and bed fee, and the cost of any implants and/or consumables used, as well as fees from other doctors involved. This can end up costing you many thousands of dollars. We will attempt to provide you with an estimate of these costs.



Kareena Private Hospital
86 Kareena Rd, Caringbah
(Level 3 Executive Suites)


Hurstville Private Hospital
37 Gloucester Road,
(Suite 4, Level 2)


St George Private Hospital
1 South St, Kogarah


Tamworth – Regional Specialists
21-23 The Ringers Rd, Hillvue NSW

Please call 6762 2321