Summary
- Informed financial consent (IFC) is the process by which a patient comes to understand the practitioner’s fee, the benefits likely to be paid by Medicare and their health fund, and the resulting out-of-pocket cost, before treatment is provided.
- There is no general statutory duty on medical practitioners to obtain IFC. The obligation is professional, arising under the Medical Board of Australia’s code of conduct, and becomes a contractual condition of payment where a service is billed under a health fund’s no gap or known gap scheme.
- IFC should be provided in writing. Email, SMS and secure electronic links are acceptable, and the patient’s acknowledgement should be recorded.
- In an emergency, clinical care takes precedence. Written information should be provided as soon as reasonably practicable after treatment, to the patient or to a person acting on their behalf, and the discussion should be documented.
- Legislation passed in September 2026 permits the Australian Government to publish the fees charged by individual specialists. The written estimate remains the figure applicable to the individual patient.
Scope of informed financial consent
IFC comprises both the discussion and the written record by which a patient understands and agrees to the cost of their care. The AMA position statement on IFC (2024) identifies four matters the patient should understand:
| Element | Description |
|---|---|
| Practitioner’s fee | The fee for the service. |
| Prostheses and devices | The cost of any implantable prostheses and devices to be used. |
| Rebates and benefits | The expected Medicare rebate and health fund benefit. |
| Potential variation | The manner in which the fee may change should the procedure be altered for clinical reasons. |
Together, these establish the patient’s out-of-pocket cost. The statement further asks that the patient be given the MBS item numbers and the names and contact details of other practitioners who will treat them during the same episode of care. It also requires disclosure of any direct financial interest the practitioner holds in the facility or associated services.
IFC applies irrespective of whether the fee is above, equal to or below the combined Medicare rebate and fund benefit. Health fund requirements may be less stringent where no out-of-pocket cost applies. Medibank’s GapCover batch header, for example, states that written IFC is not required where the patient is not charged above the GapCover benefit, although its scheme terms still ask for a written estimate for each admission. The professional expectation that the patient be informed of the fee nonetheless remains.
Sources of the obligation
Six instruments bear on IFC for specialists practising in Australia. Only health fund scheme terms constitute a direct condition of payment. Most of the remainder establish the professional standard against which a practitioner’s conduct is assessed in the event of a complaint.
| Source | Requirement | Consequence of non-compliance |
|---|---|---|
| Medical Board of Australia, Good medical practice (2020) | Practitioners should ensure patients are informed about their fees and charges in a timely manner, so that they can decide whether to proceed (4.5.3). They should not exploit a patient’s vulnerability or lack of medical knowledge when providing or recommending treatment or setting fees (10.13.1). | Failures of financial consent have resulted in findings of unsatisfactory professional conduct and reprimands. |
| AMA position statement on IFC (2024) | Written IFC before the service where possible, including item numbers, rebates, benefits and the identity of other practitioners involved. Practice staff may provide IFC on the practitioner’s behalf. | Guidance only. The AMA does not support legislating IFC as a direct legal requirement. |
| Health fund gap cover schemes | Information on out-of-pocket costs before the service, or as soon as reasonably practicable after it, and the patient’s consent on that basis. Where a known gap is charged, Medibank, nib and the Access Gap Cover funds require the information in writing, with the patient’s acknowledgement. The Bupa and HCF terms require IFC without specifying its form; Bupa requires it at the first consultation leading to the episode of care. | The scheme benefit is not payable. The fund pays its minimum benefit, or no benefit. |
| Private hospital IFC rules (Private Health Insurance (Health Insurance Business) Rules 2018; ACSQHC Advisory AS18/10) | The hospital must provide written IFC for its own charges, the expected insurer benefit and the out-of-pocket cost, and advise the patient to confirm their cover with their insurer. | Applies to the hospital. The hospital’s documentation does not extend to the practitioner’s fee. |
| Medical Board of Australia cosmetic guidelines (2023) | Additional consent requirements for cosmetic surgery, including consent (financial consent among it) obtained by the operating surgeon at least seven days before the surgery. This cannot be delegated. | Applies to cosmetic surgery. Non-surgical cosmetic procedures carry lighter requirements. |
| Fee transparency legislation (passed September 2026) | No new obligation at the point of care. Permits the Government to publish individual specialists’ fees and likely out-of-pocket costs on the Medical Costs Finder. | Patients may present with a published figure against which to compare the estimate. |
Composition of the patient’s account
For a private patient admitted to hospital, Medicare pays 75 percent of the MBS schedule fee, and a health fund that covers the treatment must pay at least the remaining 25 percent. Any amount above that total is payable by the patient, unless the service is billed under the fund’s gap cover scheme. In that case the fund pays according to its own, higher schedule, and the patient pays either nothing (no gap) or an amount not exceeding the fund’s cap (known gap).
An identical fee may therefore result in markedly different out-of-pocket costs depending on the billing basis. The billing basis should be determined before the written estimate is prepared, as the out-of-pocket figure depends on it.
An illustrative example
One procedure under three billing arrangements
- Medicare
- Health fund
- Patient
Illustrative figures only: MBS schedule fee $1,000; fund gap scheme schedule $1,500. Each fund determines its own schedule and cap, and benefits depend on the patient’s level of cover.
For services provided out of hospital, Medicare pays 85 percent of the schedule fee for most specialist services, and health funds are not permitted to contribute. The patient therefore pays the full difference between the fee and the rebate.
Content of the written estimate
A written estimate addressing the following matters should satisfy the AMA standard and the IFC requirements of the major fund schemes.
- The service
- Practitioner’s name, specialty and provider number
- Description of the procedure or service in plain language
- MBS item numbers, enabling the patient to verify their cover
- Hospital and date of service, or the expected date
- Other practitioners involved in the episode, with contact details
- Fees and benefits
- Total fee
- Expected Medicare rebate and fund benefit, stated as estimates subject to confirmation
- Out-of-pocket amount
- Whether the service will be billed under the fund’s no gap or known gap scheme
- Any prosthesis gap, and any financial interest in the facility
- Subsequent steps
- Circumstances in which the estimate may change, and how the patient will be notified
- Payment terms
- Contact for enquiries
- Patient’s acknowledgement and consent, dated
Rebates and benefits should be stated as the amounts ordinarily payable, accompanied by advice that the patient confirm their entitlements with Medicare and their health fund. A practitioner should not suggest that a patient change health funds.
Establishing the rebate and benefit
An online eligibility check (OEC) through ECLIPSE returns the Medicare and health fund benefits payable for the nominated MBS items, together with the patient’s level of cover, waiting periods, exclusions and financial status. Services Australia recommends an eligibility check to support IFC, and a further check before admission where the admission date is well into the future, so that any change in benefits affecting the out-of-pocket amount is identified. A check may be submitted up to 12 months before the expected admission date, or up to seven days after an emergency admission.
An eligibility check does not guarantee payment. A fund may still decline a claim on the basis of a pre-existing ailment, an unserved waiting period, a product exclusion or an unfinancial membership, and the outcome may differ where additional services are performed. The patient should be advised in every case that payment remains subject to the financial status of their membership. Where the fund flags a possible pre-existing ailment, the check can be repeated on that basis to give the patient a best and worst case estimate.
Timing
The AMA defines an elective service as one that is clinically necessary but can be delayed by at least 24 hours, and an emergency service as one that must be provided within 24 hours. The timing of IFC follows from this distinction.
Elective in-hospital procedures
Before admission, allowing the patient sufficient time for consideration.
- Booking Procedure and items confirmed at consultation
- Estimate issued In writing, by email, SMS or letter
- Acknowledgement Patient confirms, or raises a query
- Procedure Account issued in accordance with the estimate
Emergency procedures
Clinical care takes precedence. IFC must not delay or compromise treatment.
- Procedure No estimate possible beforehand
- Discussion documented With the patient, a relative or a person acting on their behalf
- Estimate issued As soon as reasonably practicable
- Acknowledgement Receipt confirmed before payment is pursued
The identity of the person consulted, their relationship to the patient and the date should be recorded. Under the Medibank, nib and Access Gap Cover schemes, a written estimate and the patient’s acknowledgement are still required where a gap is charged. Medibank’s manual batch header requires the names of patients whose IFC was obtained after the procedure.
Consultations and telehealth
At the time of booking, which is ordinarily the first point of contact.
The fee and expected rebate should be stated when the appointment is made and confirmed in the booking SMS or email. A current fee schedule should be available on the practice website and at the practice.
Period of notice
No minimum period is prescribed, except for cosmetic surgery, for which consent must be obtained at least seven days before the operation. The relevant test is whether the patient had a genuine opportunity to verify their cover, raise a query and reconsider before becoming committed to the procedure. For elective procedures, the estimate should be provided at the time of booking, and no later than the business day preceding admission. An estimate first presented in the anaesthetic bay is unlikely to satisfy this test, irrespective of any signature obtained.
Practitioners without a prior consultation
Anaesthetists and surgical assistants frequently have no separate consultation with the patient. The AMA places the onus on the treating practitioner to provide the patient’s details to other practitioners, and on each of those practitioners to provide their own IFC or to supply their fees for inclusion in the treating practitioner’s estimate. The operating list should be obtained from the surgeon’s rooms in sufficient time to issue an estimate before admission.
Responsibility and delegation
The AMA accepts that practice staff, or another representative of the practitioner, may provide IFC on the practitioner’s behalf. Each practitioner nonetheless remains responsible for ensuring that the patient is aware of their fees.
Recommended practice divides the process between the practitioner and the practice. The practitioner should discuss the fees with the patient personally, in a timely manner. Practice staff or a billing service then issue a written statement setting out the scope of the service and the associated charges. The patient signs or electronically confirms the statement, which is retained as the record of consent.
Recommended practice
The practitioner explains the fees. The practice documents them.
- Discussion The practitioner explains the fees and out-of-pocket amount when recommending the procedure
- Written statement Staff or a billing service issue a statement of the scope of the service and the charges
- Acceptance The patient signs or electronically confirms the statement
- Record The signed or confirmed statement is retained with the patient's billing record
Enquiries concerning the fee itself, and any discussion following an emergency, should be referred to the practitioner. Cosmetic surgery is an exception to delegation: consent, including financial consent, must be obtained by the surgeon who will operate.
No gap and known gap schemes
Where a service is billed under a fund’s gap cover scheme, IFC forms part of the claim requirements. Each fund sets its own terms. The terms of Medibank’s GapCover scheme, which also applies to ahm members, are publicly available and representative, and are cited here. Bupa, HCF, nib and the Access Gap Cover funds operate equivalent schemes. Each also caps the known gap at $500 per practitioner per episode (Access Gap Cover allows $800 for obstetric labour and delivery items), but their other conditions differ.
| Condition | Detail |
|---|---|
| $500 per practitioner’s account, per episode | The known gap cap applies to the practitioner’s entire account for the episode of care, irrespective of the number of items billed. It is not applied per item or per day. Where a surgeon bills the assistant’s fee on the same account, the combined out-of-pocket amount must remain within the cap. |
| Accounts exceeding the cap are not scheme claims | Such claims are assessed at the fund’s minimum benefit. Where an excess is identified after payment, the fund may recover it from the practitioner and refund the patient. |
| Written estimate and patient acknowledgement | Required before the service, or as soon as reasonably practicable after it. Under Medibank’s scheme, the benefit is not payable unless the patient has received the written information and acknowledged it. nib and the Access Gap Cover funds also require IFC in writing where a gap is charged. The Bupa and HCF terms do not specify the form, although written information remains preferable. Medibank’s batch header states that written IFC is not required where no out-of-pocket amount is charged, although its terms still ask for a written estimate. |
| Single consolidated account per episode | All services from admission to discharge, itemised by MBS item, stating the total fee and the full out-of-pocket amount. |
| No additional charges | No administration, booking or similar fee that does not attract a Medicare rebate may be charged. |
| Lodgement by the practitioner | The claim must be submitted to the fund by the practitioner or their billing service. A claim lodged by the patient cannot be assessed under the scheme. |
Records
A common deficiency is a clinical note recording only that IFC was obtained. In the event of an account dispute or a fund audit, the practitioner must be able to demonstrate what information was provided and when. Medibank’s audit rights, for example, extend to gap claims from the current financial year and the three preceding years.
| Record | Purpose |
|---|---|
| Estimate as issued | Demonstrates that the patient was informed of the fee, rebate, benefit and out-of-pocket amount. |
| Delivery | Date of issue and method of delivery. |
| Acknowledgement | Identity of the person confirming, with date and method. Required in writing by Medibank, nib and Access Gap Cover for known gap claims. |
| Enquiries | Questions raised by the patient and the responses provided. |
| Emergency discussion | Identity of the person consulted, their relationship to the patient, and the date. |
| Revisions | Each superseded estimate and the reason for the revision. |
Common deficiencies
The following deficiencies are common causes of fee disputes.
Stating the fee without the out-of-pocket amount
A patient informed only of the total fee may assume that most of it will be covered by their fund. The figure relevant to the patient is the amount they will pay.
The out-of-pocket amount should be stated as a separate and prominent item.
Assumptions about the patient’s cover
Waiting periods, excluded services, premium arrears and products without gap scheme access may each result in a benefit substantially lower than estimated.
An ECLIPSE online eligibility check should be performed before the estimate is issued, and the benefit stated as an estimate that the patient may confirm with their fund by reference to the item numbers provided.
Reliance on the hospital’s IFC documentation
The hospital’s documentation addresses the hospital’s own charges and advises the patient to confirm their cover with their fund. It does not constitute IFC for the practitioner’s fee.
Each practitioner should issue their own estimate, regardless of the completeness of the hospital’s documentation.
Omission of the anaesthetist and surgical assistant
The patient selects the surgeon but not, as a rule, the other members of the team. Unanticipated additional accounts are a frequent source of complaint.
Other practitioners should be identified, with contact details. Practitioners in this position should issue their own estimate before admission.
Additional items exceeding the known gap cap
An additional item identified during the procedure may take the account beyond the fund’s cap, resulting in an out-of-pocket amount to which the patient has not consented.
Likely additional items should be accounted for in the estimate, or the out-of-pocket amount held within the cap.
Unanswered enquiries
An unanswered question about cost can become a complaint even where the clinical care was satisfactory.
The account should be held until the enquiry has been answered, and the response recorded.
Publication of fees from 2026
Since late 2022 the Medical Costs Finder has allowed specialists to publish their fees voluntarily, with limited uptake: by September 2026, 106 of about 6,300 eligible specialists had done so. The Health Legislation Amendment (Improving Choice and Transparency for Private Health Consumers) Act 2026, passed in September 2026, permits the Government to publish individual specialists’ fees and likely out-of-pocket costs, derived from the Medicare, hospital and fund billing data it already holds.
The legislation does not alter the requirements of IFC. It may, however, alter the context in which IFC is given, as a patient may already have seen a published figure for the practitioner, or for a colleague, before receiving the estimate. A published average is indicative only and does not constitute a quotation. The written estimate remains the figure applicable to the individual patient, and an estimate that clearly sets out how the out-of-pocket amount is derived is the most effective response to such comparisons.
IFC with FreshClaim
FreshClaim can administer IFC on a practitioner’s behalf, within the same system used to lodge and reconcile claims. Responsibility for the fee and its disclosure remains with the practitioner.
How FreshClaim administers IFC
The practitioner provides the required details once.
- Practitioner Provides the patient's details, the procedure and item numbers, and any fee above the rebates.
- FreshClaim Prepares the written estimate and issues it to the patient by SMS and email.
- Patient Reviews the estimate and confirms it, or raises a query.
- FreshClaim Records the acknowledgement, refers any fee enquiry to the practitioner, and provides the practitioner with a copy of the IFC.
Sources
- Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. 2020.
- Medical Board of Australia. Guidelines for registered medical practitioners who perform cosmetic surgery and procedures. 2023.
- Australian Medical Association. Informed financial consent 2024 (position statement). April 2024.
- Australian Medical Association. AMA guide to informed financial consent. 2024.
- Medibank. Terms and conditions of using the Medibank GapCover scheme. Effective 19 December 2023.
- Medibank and ahm. GapCover provider guide. Effective 1 May 2017.
- nib. MediGap terms and conditions. 15 July 2026.
- Australian Health Service Alliance. Access Gap Cover billing guide. Effective 1 July 2026.
- Bupa. Medical Gap Scheme terms. 1 February 2025.
- HCF. Medicover terms and conditions. Effective 1 October 2023.
- Services Australia. ECLIPSE Online Hospital Claiming User Guide v2.0. January 2025.
- Australian Commission on Safety and Quality in Health Care. Advisory AS18/10: Informed financial consent. Version 3.0, November 2021.
- Commonwealth Ombudsman. Informed financial consent factsheet.
- Parliament of Australia. Health Legislation Amendment (Improving Choice and Transparency for Private Health Consumers) Bill 2026: bill page and explanatory memorandum.
- Minister for Health and Ageing. Better transparency and choice in health care. 16 September 2026.
This guide provides general information for medical practitioners and is current as at October 2026. It does not constitute legal advice. Health fund scheme terms are subject to change, and the current provider terms of each fund should be consulted before reliance is placed on any cap or condition.