What are preferred health care providers?

Accessing treatment from one of your health fund’s participating health care providers can lead to big savings.

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If you want to make a health insurance claim for medical or services you have received, your health fund must recognize the provider of those services. Generally, any qualified provider will be fine, but some health funds also have a list of preferred providers. While preferred health care provider programs can offer a range of benefits to fund members, they do have a few drawbacks you should be aware of before choosing a health fund. Keep reading to find out more about preferred providers and how they work.

What are preferred providers?

Preferred providers are service providers with which a health fund has a special relationship or arrangement, and that you're encouraged to use. In some cases, this could even be a dental or optical centre that is owned and run by your health fund.

You can often get discounted treatment or agreed rates if you access treatment from a health care provider featured on your fund’s list of participating providers. You may also be able to access a higher rebate from your fund under your extras policy, allowing you to save money on the cost of treatment for a wide range of conditions.

Preferred providers can encompass the following services:

  • Dentists
  • Optometrists
  • Physiotherapists
  • Chiropractors
  • Massage therapists
  • Osteopaths
  • Podiatrists

Where to find your fund's preferred providers

If your health fund does have relationships with participating providers, you will usually be able to search for your nearest supported providers through the fund’s website. However, make sure you’re aware that your fund may label its preferred providers by other names, such as participating providers, members’ choice providers or members’ first providers.

Which funds have preferred providers?

Most of the big health funds in Australia preferred providers, but the details can vary. Some funds, like ahm and HCF, maintain a network of partners. Other funds, like nib, also operate their own health centres. Click the drop down for a table that compares the details between health funds.

What are the pros and cons of preferred providers?

Pros

  • Save money. You can typically access cheaper treatment if you use one of your health fund's preferred providers.
  • Higher rebates. You may be eligible to receive a higher rebate from your health fund if you undergo treatment from a participating provider.
  • Security. When you visit one of your health fund's preferred health care providers, you can usually enjoy the peace of mind of knowing exactly how much you will get back to cover the cost of treatment.
  • Easy claims. Because the provider has a relationship with your fund, you can rest assured that it should be quick and easy to make a claim for the treatment you have received.

Cons

  • Lack of choice. If your health fund has a list of preferred providers, you may not be able to choose the health care provider you wish.
  • Lack of continuity of care. If you change from your regular dentist, for example, to one of your health fund's preferred providers, you can no longer rely on your dentist's knowledge of your treatment history.
  • In the health fund's best interest. Preferred provider programs aim to help health funds save money, not to help you access the best possible care.

Taking all these factors into account, it's important that you're aware of all the benefits and drawbacks associated with preferred provider schemes before you choose a private health fund.

Can hospitals and doctors be preferred providers?

While the term “preferred providers” usually applies to extras cover and the providers of ancillary health care services, health funds also have agreements in place with hospitals and doctors around Australia.

In order to receive your full benefit entitlement when you undergo hospital treatment, you will need to attend a private hospital or day surgery with which your health fund has an agreement. Sometimes referred to as agreement hospitals, contracted hospitals, participating hospitals or even members’ hospitals, these are hospitals with which your health fund has an arrangement that includes an agreed-upon schedule of fees that are covered by your health fund.

If you’re treated in a hospital that doesn’t have an agreement with your health fund, you could end up with significant out-of-pocket expenses.

Your health fund may also have relationships with doctors around Australia as part of its gap cover scheme. When you receive treatment in hospital by a doctor or specialist that participates in your health fund’s gap cover scheme, your out-of-pocket expenses will be reduced or even eliminated.

Contact your health fund for details on its contracted hospitals and doctors that participate in its gap cover scheme.

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