How does AGC billing work?
When your doctor chooses to participate in AGC they have the option of billing one of two ways:
1. No Gap
When your doctor charges an amount for their services that is equal to the AHSA AGC benefit (being the amount paid for by HBF and Medicare), you will pay no gap.
Medicare Benefits Schedule item number
Item description
Surgeon's fee
AHSA AGC Benefit (paid by Medicare and HBF)
Gap (paid by you)
32228
Colonoscopy
$443.70
$443.70
$0
32229
Polyp removal
$178.90
$178.90
$0
Your out-of-pocket expenses for your surgeon
$0
The information provided in the table above is for example purposes only. You may still have out-of-pocket expenses for other services, including for your anaesthetist and/or assistant surgeon.
2. Known Gap
Some doctors may still choose to charge a gap. However, if they’ve chosen to opt-in to the AGC the maximum amount that each doctor (surgeon, assistant surgeon, anaesthetist) can charge you over the AHSA AGC benefit is $500 per hospital episode, irrespective of how many Medicare Benefits Schedule (MBS) item numbers are included in your treatment.
This ruling does not apply to obstetricians, who can charge up to $800 over the AHSA AGC benefit per obstetric service or MBS item number that relates to the management of labour and delivery.
Medicare Benefits Schedule item number
Item description
Surgeon's fee
AHSA AGC Benefit (paid by Medicare and HBF)
Gap (paid by you)
32228
Colonoscopy
$743.70
$443.70
$500 (combined with below)
32229
Polyp removal
$378.90
$178.90
$500 (combined with above)
Your out-of-pocket expenses for your surgeon
$500
| Medicare Benefits Schedule item number |
Item description |
Surgeon's fee |
AHSA AGC Benefit (paid by Medicare and HBF) |
Gap (paid by you) |
| 32228 |
Colonoscopy |
$743.70 |
$443.70 |
$500 |
| 32229 |
Polyp removal |
$378.90 |
$178.90 |
| Your out-of-pocket expenses for your surgeon |
$500 |
As another example, if you require obstetric care in New South Wales and your obstetrician chooses to participate in AGC and charge you a Known Gap, the obstetrician's costs may look like the below:
Medicare Benefits Schedule item number
Item description
Surgeon's fee
AHSA AGC Benefit (paid by Medicare and HBF)
Gap (paid by you)
16519
Management of labour and birth
$2,100
$1,300
$800
Your out-of-pocket expenses for your obstetrician
$800
The information provided in the tables above is for example purposes only. You may have additional out-of-pocket expenses for other services, including for your anaesthetist and/or assistant surgeon.
Should your doctor choose to not participate in AGC, HBF and Medicare will pay up to the MBS fee. If the doctor charges above the MBS fee, you will need to cover the difference out of your own pocket.