Medicare breast reconstruction Australia
Through the public hospital system, Medicare will cover the medically necessary reconstruction that follows a mastectomy or other surgery for breast cancer. Approved doctors may also be able to put forward eligible services for Medicare’s contribution, but one should not assume the scheme will foot the bill for any given surgeon, implant, hospital, follow-up or tattooing.
Simon Bradshaw here. I prefer to put things in plain English; there is no need to make patients think they require a law degree to navigate medical billing. In brief, an Australian resident with a Medicare card can have breast reconstruction done at a public hospital. Opt for private care and it becomes a matter of Medicare, private health insurance and the odd gap payment. But get your insurer, hospital and plastic or breast surgeon to verify the funding before you start treatment.
Understanding the Coverage
It is major surgery to have your breast shape put back after a mastectomy. If you want to compare private with public care and put yourself in a position to recover without some unpleasantness from the accounts department later on, it is best to know the funding pathway in advance.
Then there is the matter of what “covered by Medicare” actually denotes. For Medicare areola tattoo rebate details, it could be an admitted service in a public hospital for which you are not charged, a rebate for a listed service, or partial backing where your private health insurance has taken care of the prosthesis and hospital costs.
The Usual Support From Medicare
As the public health insurance of Australia, Medicare can underwrite clinically required services that appear in the MBS (the Medicare Benefits Schedule). The Government is in the habit of changing item descriptions and MBS rules, so do not put much stock in a phone call; the item wording as it stands is what counts.
When it comes to breast cancer reconstruction, consultations, the surgery itself and some attendant services will be supported if they are medically indicated and billed under an appropriate MBS item by a provider who is eligible to do so. What you receive in benefit is contingent on the item, the fee of the provider and whether it is an in or out of hospital procedure.
Do not be under the impression that all is free. You may find accommodation in a private hospital, theatre fees, travel, parking, pathology, imaging, some prostheses and medicines are not part of the Medicare equation.
Procedures and Options
There is more to reconstruction than one operation. An implant or a flap using tissue from the abdomen or back might be put forward by your clinical team, or a staged plan involving areola tattooing and nipple work. The technique and timing will dictate the funding. A reconstruction done in the immediate aftermath of a mastectomy will be planned differently to one several years down the track, yet both can be deemed medically necessary.
Implant And Flap Options
With an implant there may be a tissue expander stage first. A flap is longer surgery and leaves you with a second site to recover from; enquire as to length of stay and any restrictions. While Medicare will put up its share for surgical services that satisfy MBS criteria, it is no guarantee for every accessory or expander. Public and private hospitals may have different prosthesis arrangements.
Staged Services
To get a stable result some require more than one go at it, be it for symmetry, an implant exchange or to revise a scar. Whether Medicare comes to the fore for a subsequent procedure is a question of its medical purpose and how the provider bills for it.
Most would have you believe that “reconstruction” is a single visit and then you are done. One is lucky bodies are not flat-pack furniture, even if the paperwork puts in a good effort to resemble an instruction manual. Expect a number of operations and recovery time.
Eligibility And Referral
Your eligibility for Medicare breast reconstruction is a function of your Medicare status and the clinical case for it. Make sure the hospital will have you as a public or private patient and that the provider in question is able to claim the MBS items in question.
Those enrolled in Medicare as Australian residents will have access to the funded services per the rules. Visitors or those hailing from countries with reciprocal healthcare might find their eligibility is limited; being of a certain nationality is not in itself a ticket to full coverage.
Medical Need And Referral
A referral from a specialist is generally required. A referral to a plastic or reconstructive surgeon will come from your oncologist, breast surgeon, general practitioner or another specialist in your care. The clinical team has the job of evaluating your case, looking at everything from your cancer treatment and overall health to any risks in healing, what tissue is on hand and your own objectives.
One should not put too fine a point on it: reconstructive surgery in the wake of cancer is no elective cosmetic procedure and medical necessity is therefore of some importance. Medicare is unlikely to back a service that is purely cosmetic. Have the surgeon set out how he or she would categorise the procedure in question and what MBS item numbers are to be applied.
Medicare Card And Records
It is well to have your Medicare card with you for consultations and make sure Services Australia has your name and contact details up to date. As for the paperwork – consent forms, quotes, item numbers and referral letters – I would suggest putting them all in one place, be it a file or digital folder; you do not want to be sifting through a dozen emails in the course of a recovery.
Should you need to know about claims, enrolment or the like, the information pages of Services Australia are the way to go, as opposed to an old forum post or something on social media.
Public Or Private Care
There is no one size fits all when it comes to choosing between public and private. An Australian public hospital pathway can see direct costs cut for a public patient but local surgical capacity and waiting lists are a factor. With private care you have more say over the timing and who operates on you yet you will face a number of bills. What is right for you is a matter of insurance, transport, availability of the surgeon, the demands of your cancer treatment and how you are able to handle the recuperation.
| Pathway | Common funding pattern | What to confirm |
|---|---|---|
| Public hospital (public patient) | The public system may fund eligible admitted treatment, Medicare for the services. | Reconstruction options, prosthesis, follow-up, who the surgeon is and where you stand on the list. |
| Public hospital (private patient) | Both Medicare and private health insurance could be in play, contingent on the provider and hospital. | Any co-payments, excess, theatre and doctor fees and if the hospital has an arrangement with your insurer. |
| Private hospital | Your private health insurance might cover the hospital and prosthesis while Medicare rebates the medical side. | Get every quote from the provider and check for exclusions, policy waiting periods and any gap payment from your insurer. |
Logistics And Waiting Lists
If you are going the public route there will be a waiting list. Find out if it is measured from the time of your referral, a specialist’s assessment or the end of your cancer treatment; they are distinct things and it is easy to get a false impression of the timeline by conflating them.
Then there are the less attractive details to plan for. Post-surgery you will want someone to be with you and to put in a word for meals and dressing, and you must consider getting home. Public transport is hardly an option straight after an operation and parking at the hospital is not cheap. Make allowance for this in your cost estimate.
MBS Item Numbers
These serve to denote services for which a Medicare benefit is possible but they are not a price list, nor do they ensure a free ride or tell you what the outcome will be. For the rules and descriptions the government source is MBS Online. Since the notes and numbers are subject to change, get the current ones from your provider before you give your consent.
Benefit Versus Provider Fee
On the question of benefit versus what the provider charges, the latter can exceed the MBS fee and leave you with a gap to pay. Some will bulk bill, others will put a quote in writing. Be sure the quote is comprehensive and not just a line for “reconstruction” if you are to make an informed call. It should cover the anaesthetist, assistant, imaging, pathology, hospital fees and the like.
Claims
The provider can put in a claim electronically or you can do so via Medicare. Hold on to your invoices and receipts until you see it in your history. In the event of a rejection, do not jump to the conclusion that the treatment is not covered, enquire as to what eligibility rule or item was at issue.
Services Australia will deal with the administration of a claim but they cannot assess you clinically or vouch for a surgeon’s billing. That is for the surgeon’s rooms and your insurer to address.
Out-Of-Pocket Costs
The out-of-pocket element of breast reconstruction is highly variable. It is a function of the hospital you use, whether multiple operations are in order and the fees of the surgeon and anaesthetist, as well as your private health policy and any excess or co-payment.
You will not find a single national price to be relied on for every patient. Put a red flag up on any one-figure answer given with assurance by someone who has not put questions to you on the matter of insurance, technique or whether the treatment is public or private.
Some costs have a way of taking people by surprise
Then there are the specialist invoices that come in separately, an anaesthetist gap, hospital excess and fees for pathology or imaging. Add in garments, medicines, travel, parking and time off work that is not paid for. And should a revision be required and was not part of the original estimate, that is more cost.
It is best to get an itemised estimate in Australian dollars prior to any treatment and make clear if it is a firm quoted fee or simply an estimate. See if the quote is for one side or both, for all the stages you have in mind or just one, and does it cover nipple reconstruction or areola tattooing. You want written provider fees and the MBS item numbers from them.
- Put in a request to your insurer for pre-approval in writing, covering prosthesis limits as well as co-payment and excess.
- Make sure you know who is going to be billing separately and how recovery at each stage will impinge on your work, driving and other duties of care.
Private Health Insurance
The extent of your breast reconstruction cover under private health insurance is a function of the service itself, your policy and its exclusions, waiting periods and level of hospital cover. Medicare can put in for some eligible medical services not within the hospital benefit, while hospital cover may help with what is done when admitted.
Do not think insurance approval means you are not going to have to pay; a policy might have a contract with the hospital but the doctor’s charges could be in excess of what the insurer recognises.
What to put to your insurer
Find out if they have agreements with the specialists and hospital of your choice, if a waiting period is in force and if the prosthesis is covered as part of your reconstructive surgery after mastectomy. Get the item numbers for their assessment. In the case of a staged procedure, is the first admission all that is approved or the whole course? Jot down the reference number and the name and date of the staff member. It is not as pleasant as a walk on the beach but preferable to having to make your case to a call centre with surgical drains in place.
Areola Tattoo Rebates
A trained practitioner, nurse or clinic may do an areola tattoo to give the look of an areola post-reconstruction, as per the treatment plan and local custom. But the rules in Australia do not amount to a guarantee from Medicare to put you back for the service. There has to be an MBS item and the service must be of a medically necessary nature and so on.
What To Confirm First
Before you book, ask the reconstructive team if they are recommending the tattoo or nipple reconstruction and if it is a separate bill or part of the hospital package. Do not take it for granted that an invoice with an MBS item number from the tattoo provider will result in a rebate; check with Services Australia, your insurer and the hospital for the definitive word on the Medicare position. If there is no applicable item, you may be looking at a private bill even for a medically necessary reconstruction.
Checking Claims Before Surgery
A quick check on funding before the operation will save you from a lengthy dispute down the track. The onus is on you to put your treatment plan before those who have a say in the various elements of the bill: the surgeon’s rooms, the anaesthetist, prosthesis provider, hospital admissions and your private insurer.
Proceed in this manner: make sure Medicare eligibility is in order, put the MBS items on paper, get the fees from the provider and if there is private care, have it sanctioned by the insurer. And be sure to find out what is in store should the operation take an unexpected turn.
- You will need to see Services Australia and your own treating team to be certain of any referral or enrolment requirements with Medicare.
- Get a written estimate that is itemised and has the MBS numbers.
- Make enquiries as to whether you are looking at public hospital waiting lists or a private admission.
- As for insurance, check on the excess, co-payments, exclusions and any gap or prosthesis limits.
- Put all your invoices, quotes and claim records where they can be found.
Frequently Asked Questions
One does not have to look hard to misread Medicare so these are common queries. The answers set out the general position, though your individual case will require confirmation from Services Australia and your provider.
How Do I Contact Medicare Australia?
Via Services Australia, using any of the service-centre, online or telephone options you will find on the official Medicare site. Be prepared with your card, claim documents and referral details. If it is a matter of surgical funding, ring the surgeon’s rooms as well; Medicare will tell you the rules of a claim but will not put a figure on the provider’s fees.
Are There Local Offices For Medicare?
Services Australia has service centres and other means of contact, but do not make the journey without first checking the official information as to what is available where. A local office can be of assistance with a claim or enrolment, not in telling a specialist what reconstruction technique to put forward.
What Is Medicare?
Australia’s public health insurance. It covers eligible medical services per the Medicare Benefits Schedule and gives patients under the public system access to hospital treatment. It is not a blank cheque for every healthcare or private expense.
Can NZ Citizens Access Medicare In Australia?
There may be eligibility for some New Zealand citizens under reciprocal or other arrangements but it is circumstance dependent. A New Zealand passport is not in itself a guarantee of full access, so have Services Australia verify your standing prior to any treatment.
Will Medicare Cover All Reconstruction Costs?
Not necessarily. While it will underwrite eligible services, one is left to pay for medicines, travel, parking, prostheses, private gaps, hospital charges and even some areola tattoo work. Have a complete estimate in writing and go over each part before you give your consent.
A Funding Plan With Fewer Risks
It is possible to have Medicare cover breast reconstruction in Australia, especially post cancer surgery when medically required, but every case is different. You might have lower costs at a public hospital but then face a wait; in the private sector you have more say on timing but the bills are more of a headache.
Simon Bradshaw would have it simple: get the MBS item numbers and an itemised quote, confirm your eligibility with Medicare and talk to your insurer. Consider areola tattooing a separate issue for funding unless your providers make clear they are covering it. A little diligence in questioning ahead of surgery goes a long way to avoid expense and administrative trouble down the track.
