The cost of a colonoscopy: Public vs private

Medicare covers the entire cost of a colonoscopy in a public hospital if you’re a public patient. Once you have a referral to a gastroenterologist, you’ll be put on a public waiting list for a colonoscopy.

The median waiting time for a colonoscopy through Australia’s public healthcare system after a positive faecal occult blood test (FOBT) was 84 days in 2021, with many people waiting longer.⁴ The ideal time between positive screening and colonoscopy recommended by Bowel Cancer Australia is 30 days,⁵ which means that, in many cases, you’ll be waiting much longer than recommended.

The average cost of a colonoscopy procedure with insurance in a private hospital (with or without a biopsy) is $1,300 for the specialist fees and $710 for the hospital fee, based on data from the Department of Health.³ However, this isn’t always the price you’ll pay as costs vary between doctors and hospitals.

In 2022-23, 76% of privately insured patients who were covered for colonoscopy had no out-of-pocket expenses (not including excess or co-payments), as their health insurance covered these costs. Those who did pay had an average out-of-pocket cost of $180.³

Medicare covers 75% of the Medicare Benefits Schedule (MBS) fee for private patients, and private health funds cover the remaining 25%. If you’re uninsured and treated privately, you’ll be responsible for paying the remaining 25% yourself, plus any hospital costs and gap payments.

Doctors and specialists can set their own fees, which means there may be a gap payment to cover the difference between what doctors charge and what Medicare and private health insurance cover.

Private hospital insurance can only cover you when you’re admitted to hospital as a private patient, so if you receive treatment in an outpatient facility, you won’t be able to make a claim.

The MBS is a list of item numbers and corresponding prices for medical services and treatment covered by Medicare, which the Australian Government deems a fair amount to cover the cost of a procedure.

There are 12 different MBS item numbers for a colonoscopy related to inspecting the bowel and polyp removal (polypectomy); the item number you’ll be charged will be based on your medical history and the events of the specific procedure.

Remember, the listed fees are only a part of the total cost of treatment and expenses you might have to pay. For example, you may also have to pay an excess when you claim on your private health insurance, or your doctor could set their fee higher than the MBS fee. There may also be costs charged by the hospital, such as accommodation and theatre fees.

Hospital insurance is categorised into tiers of cover (Basic, Bronze, Silver and Gold), which are standard across all health insurers. Colonoscopies are a minimum requirement in the Bronze tier and above under the treatment category ‘gastrointestinal endoscopy’.

With health insurance for a colonoscopy, your policy will pay a benefit towards the following costs (provided you’ve served any waiting periods prior to claiming):

• Proctologist fees
• Anaesthetist fees
• Assistant nurse and doctor fees
• Operating theatre costs
• Hospital accommodation (if staying overnight)
• Any consumables like dressings and disinfectants
• Admitted in-patient consultations
• Any prescriptions or medications used by the hospital.

Yes, you can use your private health insurance in a public hospital and be admitted as a private patient. In this instance, the hospital charges your health insurer the 25% difference between what Medicare covers for public patients and the cost of the treatment.

Also, most public hospitals are treated as agreement hospitals by private health funds when it comes to out-of-pocket costs, even if there is no formal agreement.

Regardless of whether you’re going to a public or private hospital, make sure you ask your health insurer and the hospital about all potential out-of-pocket expenses you may be charged for your treatment.

You’ll need to serve a two-month waiting period before you can claim on colonoscopy treatment. If you’ve shown any signs or symptoms that would require a colonoscopy within six months of starting your private health insurance policy, you may be required to serve a longer waiting period. In most cases, the insurer will deem this a pre-existing condition and require you to serve a 12-month waiting period instead.

If you switch over to a new health fund but maintain your current level of cover, you won’t need to re-serve any waiting periods you’ve already served. However, when switching policies or health funds without having finished a waiting period, you’ll need to pick up where you left off.

Some hospitals and specialists have an agreement with private health insurers where you won’t have any out-of-pocket payments for hospital fees or you’ll know what the gap payment will be beforehand. These are known as no gap and known gap agreements.

Keep in mind that other doctors who may be involved in a colonoscopy (e.g. your anaesthesiologist) might not have the same agreement with your health insurance provider. Depending on whether they charge above the MBS-listed prices for the procedure, you may have out-of-pocket costs for these assisting health professionals.