MBS fee vs private health fund gap fee

These figures are related, but they are not interchangeable.

MBS fee

The MBS fee is the schedule fee assigned to a Medicare item. Medicare benefits are calculated by reference to the MBS rules and the type of service.

Health fund gap scheme rate

A private insurer may publish a higher amount under a participating medical gap arrangement. The fund’s schedule may set the maximum recognised fee, benefit or scheme amount for eligible claims.

Why the amount paid can still differ

Actual payment can depend on the patient’s insurance, the provider’s participation, date and place of service, provider number, correct item combinations and fund-specific claiming rules.

What practices should do

Check the current MBS item first, then check the applicable insurer schedule and scheme terms. Keep evidence of the schedule version used for the date of service.