Catholic Health Australia has made a submission on informed financial consent and split billing practices. CHA supports a single definition of informed financial consent established in Commonwealth law and applying across the professions, and supports firm action on split billing. The submission then argues three further points: the design of fee transparency matters as much as the decision to require it, because international evidence indicates that publishing individual prices in markets like this one can raise prices rather than lower them; disclosure alone will not reduce what patients pay; and transparency obligations should extend to insurers, whose gap and preferred provider arrangements are frequently the largest single determinant of what a patient pays.

Where the disclosure gap actually sits

Hospitals accredited under the NSQHS Standards are already required to provide written informed financial consent covering the procedure, the item number, the hospital fee, the insurer benefit, estimated co-payments and excesses, a statement on cost variability, identification of other providers who may bill separately, and a signed patient acknowledgement. The hospital component of an episode of care is, in practice, the most transparent component.

The persistent gaps identified in consumer research relate overwhelmingly to medical practitioner fees, particularly for specialist consultations and the medical component of procedures, which hospitals neither set nor control. Reform should target that gap. It should not add duplicative obligations to hospitals that already meet detailed accreditation requirements, and it should not make hospitals or lead practitioners liable for fees charged by independent practitioners over whom they have no authority.

CHA supports a single national definition established in Commonwealth law that settles what must be disclosed, when, in what format, and with what consequence when it is not. The current position, in which the expectation is endorsed in principle by every professional body but defined differently by each and enforceable by almost none, serves neither patients nor providers. A patient cannot reasonably be expected to know that their surgeon, anaesthetist and dermatologist each operate under materially different disclosure expectations.

Why the design of transparency matters

CHA supports using data to improve fee transparency, and supports the Medical Costs Finder built on the aggregate Medicare claims data the Commonwealth already holds. Mandatory publication of individual practitioners’ fees is a different and considerably stronger instrument, and CHA’s view is that it needs much more careful consideration, because the form transparency takes determines whether it lowers costs or raises them.

The international evidence deserves close attention. In 1993 the Danish competition authority began publishing firm-level transaction prices for ready-mixed concrete, intending to sharpen competition. Within a year average prices rose by 15 to 20 per cent, as publication allowed firms to observe one another’s discounting and reduced the intensity of price competition. It was the publication of individual firm-level prices, not aggregate market data, that produced this result.

Health care evidence points the same way where conditions are similar. Following public disclosure of hospital cost information in the United States, hospitals in the lowest quintile of the cost distribution recorded the largest percentage increases. Analysis of US disclosure laws finds bidirectional convergence, with high-price hospitals reducing prices while low-price hospitals increase them, and warns that convergence can settle at a narrower band of relatively higher prices. Evidence from Japan associates disclosure of service prices with increased use of tests and imaging and higher total spending.

The evidence also identifies when transparency does reduce prices. The New Hampshire state transparency website reduced negotiated prices for surgical procedures by around 5 per cent and radiology by around 9 per cent, but the reductions were driven by insurer and provider negotiation rather than by patients shopping on price, and only about 1 per cent of state residents ever used the website. Australian research reaches a consistent conclusion, noting that only around 88 of more than 6,300 eligible specialists had voluntarily published their fees by the end of 2025.

Specialist medicine has features that cut both ways: patients are referred rather than shopping freely, demand is inelastic, provider numbers are constrained in many specialties and regions, and fees are often taken as a proxy for quality. Those are precisely the conditions under which published individual prices can function as a floor and a focal point rather than a ceiling. Where a patient has no information about quality, price becomes the only available signal of it, and Australian analysis finds that higher fees are not systematically associated with better outcomes.

What drives fees, and the case for measuring it

MBS indexation was frozen from 2013-14 and for an extended period to 2017-18, was lifted only progressively to 2020, and has been indexed at low rates since. Where rebates have grown more slowly than the cost of delivering a service, some part of the growth in patient out-of-pocket costs represents a transfer of cost from government to patients rather than a change in fee-setting behaviour by practitioners.

CHA does not assert what that proportion is. The submission asks the Department to establish it, because the appropriate policy response differs depending on the answer. The analysis is tractable at item level: for high-volume procedures such as hip and knee replacement, the recommended fee, the Medicare rebate and the insurer contribution have each moved at markedly different rates over the past twenty years. On medical indemnity, the available evidence is mixed and the position is contested, which is precisely the reason to establish it rather than rely on assertion from any party.

How MBS item use drives out-of-pocket costs

Informed financial consent and the Medical Costs Finder make costs visible. Neither addresses how those costs are generated. A significant and under-examined driver of unpredictable out-of-pocket costs is the way MBS items are selected and combined in billing: selection of the highest-rebate item where more than one could describe a service, co-claiming combinations to maximise total billing for a single episode, splitting services across multiple days to circumvent the multiple operation rule, and billing patterns that vary between practitioners performing equivalent procedures.

CHA recommends a standing program of billing-pattern analysis using the claims data the Department already holds. This is not a novel capability, and there is clear precedent for acting on the findings: from 1 November 2017, co-claiming of subsequent attendance items with a broad group of surgical operations was blocked on the recommendation of the MBS Review Taskforce. The value of a standing program is that it connects three responses that currently operate separately: compliance and PSR referral where billing is an outlier, structural amendment through the MBS Continuous Review where item combinations produce results the Schedule never intended, and descriptor clarification and profession-led education where variation is legitimate.

Practitioners performing clinically equivalent work often bill it differently depending on where and when they trained. The consequence for patients is that the rebate they receive, and the gap they pay, can depend less on the care they received than on the billing habits of the practitioner they happened to see. If item selection is opportunistic, no disclosure framework can produce reliable estimates, because the estimate depends on which items the practitioner will choose to bill.

When a single figure is not possible

For some procedures the final cost genuinely cannot be known in advance. Endometriosis surgery is the clear example. The severity and extent of the disease are frequently established only at operation, and the items ultimately billed depend on intraoperative findings. Two patients with identical referrals can leave hospital with very different accounts, and neither their gynaecologist nor their hospital could have quoted a single accurate figure beforehand.

A rigid single-figure requirement would either mislead patients or, worse, push practitioners to quote at the top of the plausible range to protect themselves, which would itself become a fee escalator. CHA recommends that the standard require a best estimate expressed as a range, a plain statement of what drives the variation, identification of the other providers who may bill, and an obligation to update the estimate where the treatment plan changes materially.

Technology choice produces the same effect. The MBS rebate attaches to the underlying procedure, so there is no separate item recognising a robotic approach, and the costs specific to the technology sit outside the rebate. Two patients undergoing the same listed procedure can face materially different out-of-pocket costs depending on the technology used, and that difference is invisible in the item claimed.

A third structural reason is that parts of an episode attract no Medicare benefit at all, and others attract a benefit that cannot be calculated in advance. Where a surgical assistant is a suitably qualified nurse rather than a medical practitioner, no benefit is payable and the patient is liable for the entire fee. Anaesthetic items are time based, so only an estimate is possible beforehand. Neither is a disclosure failure; both are features of the Schedule, and they fall on components of the episode the patient did not choose. A patient chooses their surgeon. They rarely choose the anaesthetist and almost never choose the surgical assistant.

Split billing, technology fees and payment practices

Charging a patient an administration or booking fee alongside a bulk-billed service, or alongside a no-gap or known-gap arrangement, defeats the purpose of those arrangements and transfers cost to patients in a form deliberately designed to escape scrutiny. The reported scale, with 29 per cent of patients charged administration or booking fees and hidden fees and upfront deposits potentially totalling $20 million, warrants a legislative response rather than reliance on untested consumer law.

Separately charged technology fees have the same effect: cost moves outside the visible billing arrangements, outside the rebate, and outside the data the Commonwealth and insurers rely on, and the charge is generally not claimable by the patient from either Medicare or their insurer.

On a single bill for an episode of care CHA’s position is more qualified. A single consolidated estimate before treatment is achievable and should be required for planned care, while a single consolidated invoice across what are legally independent businesses raises real questions of payment flows, liability and timing.

Two payment practices impose avoidable financial pressure. A patient told their gap will be several hundred dollars may nonetheless be asked to fund the whole account, often several thousand dollars, and then wait to be reimbursed. And a patient who has paid in full generally cannot be reimbursed until the hospital and each treating practitioner has lodged a claim, so the patient carries the full cost for as long as the slowest provider takes to lodge, with no visibility of the delay and no means of resolving it.

Transparency on the insurer side

The consultation paper considers transparency almost entirely as something practitioners and hospitals owe patients. Gap arrangements now operate in tiers, and the experience of CHA members is that the criteria determining which hospitals and practitioners are eligible are not published, so a patient cannot establish, before choosing a policy, a hospital or a practitioner, whether their care will fall inside or outside a preferred tier.

Which tier applies is often the single largest determinant of a patient’s out-of-pocket cost, and it is set by the insurer rather than by the practitioner or the hospital. A practitioner can disclose their own participation but cannot explain criteria they have never seen. CHA does not oppose arrangements that reduce or remove out-of-pocket costs. It asks that they be transparent, because a patient cannot be given a reliable estimate when a material determinant of that cost is disclosed to no one.

Disclosure across the treatment cycle

For many conditions the procedure is one stage of a longer and more expensive sequence. A cancer diagnosis may involve surgery, then radiation oncology, then medical oncology, with repeated imaging and pathology throughout, much of it delivered out of hospital where no insurer benefit is payable. A patient given an accurate estimate for their surgery can still face substantial and entirely unanticipated costs over the following year. CHA asks that disclosure across the full treatment cycle be stated as a medium-term objective, starting with high-cost, protocol-driven pathways, with cancer care the obvious first candidate.

The preferred regulatory approach

CHA does not consider that any single option presented in the paper is sufficient on its own, and cautions against the two extremes. Voluntary guidance alone has demonstrably not delivered. A new standalone regulator would duplicate existing bodies, take years to establish and add a further door to an already confusing array of complaint pathways.

The preferred approach combines four elements: a single legislated definition in Commonwealth law; enforcement through existing Medicare compliance machinery with a carefully expanded PSR remit for serious or repeated failures; clarified application of the Australian Consumer Law, with ACCC guidance confirming that failure to disclose unavoidable fees before a patient commits to treatment can constitute drip pricing or misleading conduct; and, most importantly for patients, a direct remedy that does not depend on any regulator’s caseload.

On that last element the submission names a sequencing point: the Parliament is currently legislating visibility, through the publication powers in the Bill, before it has legislated accountability. Courts have already held that where no higher fee was agreed in advance, the MBS scheduled fee may be implied as the reasonable fee payable and amounts above it are irrecoverable. Codifying that principle, so that undisclosed fees above a properly provided estimate range are simply not payable, aligns every practitioner’s commercial interest with disclosure. It requires no new regulator, no complaint, and no navigation of the pathways the paper correctly describes as complex and inaccessible.

Keeping the problem in proportion

The evidence indicates that inadequate disclosure and excessive charging are real problems, but concentrated ones, while public discussion frequently generalises well beyond that to specialists as a group and to private care as a whole. That generalisation has consequences CHA members see in their hospitals: patients who could be treated privately, promptly and at modest cost decide not to be, elect public treatment, or defer care.

CHA is not suggesting the problem be understated, and this submission recommends firmer regulation than the current framework provides. The point is that the Commonwealth holds the data to establish the size and distribution of the problem, and publishing that analysis alongside the reform would allow the response to be targeted proportionately. Reform grounded in published measurement is more durable than reform driven by contested advocacy.

The 29 recommendations

A single, enforceable standard

1. Establish a single definition of informed financial consent in Commonwealth law, applying across the health professions, specifying what must be disclosed, when, in what form, and the consequence where it is not.
2. Target reform at the gap that actually exists. Do not duplicate the written IFC obligations hospitals already meet under the NSQHS Standards and the second-tier eligibility rules, and do not make hospitals or lead practitioners liable for fees set by independent practitioners over whom they have no authority.
3. Require, for planned procedures where the final cost depends on clinical findings, a best estimate expressed as a range, a plain statement of what drives the variation, identification of the other providers who may bill, and an obligation to update the estimate where the treatment plan changes materially or to explain the variance promptly afterwards.

Fee transparency and publication

4. Build the Medical Costs Finder on the aggregate Medicare data the Commonwealth already holds: typical fees, medians and ranges by service and region, without depending on voluntary participation by practitioners.
5. Publish fees in context and as distributions. Present every fee alongside the MBS rebate, the typical insurer benefit and the resulting out-of-pocket amount, and as medians with ranges rather than single figures, so that an individual high fee reads as an outlier rather than the going rate.
6. Publish quality information alongside price wherever it exists at the level being published, and work with the Department and the Australian Commission on Safety and Quality in Health Care to establish what can responsibly be published, at what level and with what risk adjustment.
7. Build the Medical Costs Finder into referral workflows, so that the parties with negotiating leverage can act on the information.
8. If mandatory publication of individual practitioners’ fees proceeds, legislate a review of movements in the distribution of specialist fees within two years of commencement, to be reported publicly.

Establishing what drives fees

9. Undertake and publish analysis of the relationship, over at least the past decade, between movements in MBS rebates, private health insurance reimbursement including gap scheme benefit levels, and the costs practitioners face in private practice.
10. Establish the realistic range of medical indemnity cost increases by specialty, rather than relying on assertion from any party.
11. Publish the Commonwealth’s own quantification of the size and distribution of excessive charging: the spread of fees relative to rebates by specialty and region, the share of services delivered with no gap or a known gap, and the extent to which high charging is concentrated among a minority of practitioners.

Billing and item use

12. Establish a standing program of billing-pattern analysis focused on MBS item selection and combination, using the claims data the Department already holds.
13. Connect that analysis to three existing responses: referral through compliance and PSR pathways where billing is an outlier, structural amendment through the MBS Continuous Review where item combinations produce results the Schedule never intended, and descriptor clarification and profession-led education where variation is legitimate. Publish aggregate findings annually.
14. Include within the program variation in item use between practitioners and between training cohorts for equivalent presentations, and engage the medical colleges formally in that work.
15. Design the analysis to distinguish technology approach where the data permits, so that variation attributable to technology is separated from variation attributable to fee-setting.

Amending the Schedule where uncertainty is structural

16. Determine how the costs of established technologies such as robotic assistance are to be recognised, through the item structure, prostheses and device arrangements, or hospital and insurer contracting, rather than by separate charge to the patient at the point of care.
17. Examine a fixed or banded anaesthetic benefit attaching to a listed procedure, so that a patient can be given a firm figure rather than a range.
18. Examine a benefit for surgical assistance where that assistance is clinically necessary, irrespective of whether the assistant is a medical practitioner or a suitably qualified nurse.

Split billing and payment practices

19. Prohibit expressly the charging of any fee associated with a bulk-billed service beyond the assigned benefit, and require that any fee associated with a service claimed under a no-gap or known-gap arrangement be disclosed to, and reflected in the arrangements with, the relevant insurer.
20. Extend any prohibition on split billing expressly to separately charged technology fees, however they are described.
21. Require a single consolidated estimate before treatment for planned care, require all invoices to identify the episode of care to which they relate, and test the feasibility of consolidated billing through the benchmarking and eClaiming infrastructure that already connects hospitals, practitioners and insurers.
22. Provide that where a service is claimable, a patient is not required to pay more than their disclosed out-of-pocket amount in advance, with the practitioner claiming the Medicare and insurer components directly, and revisit the Department’s current consumer guidance accordingly.
23. Examine claim lodgement practices and timeframes, so that patients are not left out of pocket because of provider-side delay.

Insurer obligations

24. Place a corresponding disclosure obligation on insurers, requiring them to publish which hospitals and practitioners are covered under each tier of gap arrangement, the criteria for inclusion and exclusion, and how costs arising from complications or extended stays are treated.

Scope over time

25. State disclosure across the full treatment cycle as a medium-term objective and begin the work, starting with high-cost, protocol-driven pathways. Cancer care is the obvious first candidate.

Enforcement

26. Do not establish a new standalone IFC regulator, and do not rely on education and voluntary compliance alone. Neither extreme will deliver.
27. Enforce through existing Medicare compliance machinery, with a carefully expanded PSR remit for serious or repeated failures.
28. Clarify the application of the Australian Consumer Law, with ACCC guidance confirming that failure to disclose unavoidable fees before a patient commits to treatment can constitute drip pricing or misleading conduct.
29. Legislate that fees not disclosed before treatment are not recoverable, so that undisclosed fees above a properly provided estimate range are simply not payable. This is the single most effective measure available, because it requires no complaint, no regulator and no new institution.