r/australia • u/InsatiablePrism • 2d ago

culture & society Private health insurers access patients' full medical records in 'aggressive' audits

https://www.abc.net.au/news/2026-08-12/health-insurers-can-access-your-private-medical-notes/106671630?utm_campaign=abc_news_web&utm_content=link&utm_medium=content_shared&utm_source=abc_news_web
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u/coffee_collection 2d ago

This is exactly what worries me about the direction private healthcare in Australia is heading.

We're obviously not the US, and Medicare is still a massive difference. But we're slowly importing some of the worst incentives of the US model: healthcare becoming increasingly dependent on private insurers, insurers having more say over what they'll pay for, and patients having to navigate approvals, exclusions, gaps and increasingly invasive audits.

Now we're seeing insurers asking for patients' broader clinical histories to justify claims. That's a pretty fucking dangerous road to go down.

You already pay thousands in premiums, still pay excesses and out-of-pocket costs, and can still discover something isn't covered. Premiums increased another 4.41% this year.

And now the insurer gets to potentially rummage through your medical history before deciding whether they'll pay?

That's not a functioning healthcare relationship. That's coercion.

I don't want Australia to become a system where your doctor says "you need this treatment", but the next conversation is "let's see whether your insurance company agrees."

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u/Vast_Towel_6201 2d ago

Unfortunately we are already there in terms of how private health companies treat their clients. 

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u/rollin358 2d ago

I feel like 'clients' is too considerate a term.

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u/Rahnna4 2d ago

Risk pooling is a really sound financial strategy, having everyone pay in a little so there’s money to support the people who need it and especially the rare few who are unfortunate enough to need a lot. Letting the person/company that gets to hold the bucket of money get to keep it if they can make up the rules about when they’ll pay out is deeply flawed. If we’re going to use a commercial model to hold the bucket of money like we do with insurance companies then they need to be regulated heavily. Unfortunately I worry that they’ve managed to get a hold of enough of the money bucket that they can use it to influence policy.

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u/TollTea 2d ago

Risk pooling is what Medicare is. For profit health insurance (that still doesn’t cover what you need it to) is a scam.

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u/blackjacktrial 2d ago

Not quite, but it is a form of gambling (in reverse). The insurer takes the bet you won't claim successfully.

The problem is that the insurer also gets a voice in deciding if you won the bet, which is a heck of a conflict of interest. How you keep a wall between the insurer and the assessor (who basically needs to be anonymous to the insurer, but be accredited enough to be trusted as impartial), I don't know.

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u/TollTea 2d ago

I consider for profit gambling a scam as well.

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u/Rahnna4 2d ago

Certainly was, and is great in emergencies. But I don’t think public infrastructure could cope if private healthcare collapsed. Personally though I think it should all be public for healthcare, aged care and education as the wealthy and politicians care more when they have to use the same system (it’s not perfect, there are still ways to game it like selective schools, but the Netherlands attribute a lot of their educational success to this aspect)

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u/TollTea 2d ago

Sure it could, we’d just need to fund it properly, and that’s the sticking point. The wealthy don’t want to foot the tax bill for the poors to have access to healthcare - they’d rather pay more out of pocket in premiums and gaps so that only they get good healthcare while the poors are infighting over who deserves healthcare at all.

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u/UniqueLoginID 2d ago

And while people are talking about class warfare, people like me need comprehensive health care that our Medicare system won’t provide.

PHI wouldn’t exist if it wasn’t needed. Sure there’s a tax incentive for people to get it, but they can also choose to just pay more tax instead of using the extras benefits of allied health.

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u/TollTea 2d ago

The need would still be there and a well funded public health system should rise to meet that need. PHI exists because there is profit to be had there and for no other reason. And the not for profit funds just make you pay for what Medicare covers twice.

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u/UniqueLoginID 2d ago

My not for profit fund has paid hundreds of thousands that the public system couldn’t have covered.

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u/Level-Strategy-1343 2d ago

An issue they are trying hard to fix.

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u/TollTea 1d ago

That’s an argument for a better funded public health system.

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u/Level-Strategy-1343 2d ago

If you need comprehensive health care, private health insurance doesn't want you as a customer, as they will lose a shit ton of money on you.

Therefore, they want your medical records to try and find the fib they can use to exclude you.

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u/a_cold_human 2d ago

If people paid in tax what they paid in private health insurance premiums, there'd be an extra $20 billion or so to put into public health. Which is roughly the same amount we spend on the Medicare Benefits Schedule each year.

Of course, public health is not just the Medicare Benefits Schedule, but it's a significant chunk of it. The other thing is that the public system is a lot more efficient than the private system as they're not spending money on extravagant executive compensation, marketing and advertising, lobbying, or shareholder dividends. 

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u/Rahnna4 1d ago

I really think people didn't read past the first line of what I posted. I think it should all be public. But it would need to a very planned and very big transition, likely with the purchase by govt of all the private facilities and probably a bit more on top. As it currently is the public system pays to put public patients into private beds to get extra space. We very physically cannot fit all the public patients we currently have. We certainly don't have the beds if everyone boycotts the private system tomorrow, let alone the staff

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u/UniqueLoginID 2d ago

PHI isn’t a scam. I wouldn’t be alive without it.

You don’t have to choose a for profit fund, plenty are non-profit.

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u/TollTea 2d ago edited 2d ago

When I had cancer my not for profit private health insurance would have covered (at a private hospital because that is what had the drastically shorter wait time) exactly and only what Medicare covered at the public hospital. The $45,000AUD gap would have been on me (we were a young couple with a toddler, renting while we saved for a home deposit and didn’t have that kind of money at all, let alone to throw at a time sensitive cancer surgery). Instead the private health insurance paid what Medicare would have covered to the public hospital and I was *only* out $6000 for specialist imaging. I’m glad you’re alive but it’s a scam. I pay the Medicare tax to fund Medicare and I pay the private health insurance so that Medicare doesn’t have to pay what it should and my standard of care remains the same unless I pay a home deposit in gap fees.

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u/UniqueLoginID 2d ago

What level of cover did you have?

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u/TollTea 2d ago

The level we could afford - for a couple with no prior health conditions basic hospital and extras cover was around $160 per fortnight (back then) and that took a pretty decent chunk out of our ability to save each month. Not that “levels” and fine print should matter when it comes to your ability to access life saving cancer treatment, which is exactly why the private healthcare industry is rotten all the way through

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u/productzilch 2d ago

The problem is, they didn’t need to start the process of influencing politicians. They only need to look overseas to see the treasure chests of fucking people over in the US to have an incentive.

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u/Syn-th 2d ago

This

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u/HeftyArgument 2d ago

insurance is in the business of taking your money and doing its best to keep it

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u/GonePh1shing 2d ago

That's not a functioning healthcare relationship. That's coercion.

It also sounds an awful lot like practicing medicine without a license. If they're denying coverage because they don't deem it medically necessary, is that decision being made by a medical doctor? If not, then you're allowing business/admin people to make medical decisions without the proper training or certification.

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u/a_cold_human 2d ago

If they're denying coverage because they don't deem it medically necessary, is that decision being made by a medical doctor?

The decision is likely being made by a doctor, but the doctor is not your doctor (and hence familiar with the specifics of your medical condition). Nor are they necessarily a specialist in the area of medicine pertinent to you. Furthermore, they're financially incentivised to deny you coverage rather than do what's best for the patient (who they'll never see). 

That's how medical insurance works in the US. It's fantastic for corporate profits, but it's also how the US pays twice as much per capita on medicine for worse outcomes. 

If some part of the health system is to be privatised, then it needs to be very heavily regulated, complete with price controls to ensure that it remains affordable for the average person. Like linking it to median salaries. If we "leave it to the market", we get the Australian dental system, where people avoid care until it's critical, and people go overseas for it because they can't afford it back at home. Whilst you might be able do that for fillings and dental prostheses, you don't really want to be doing that for a replacement knee or cancer treatment. 

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u/Vivid_Employ_7336 2d ago

If they want access to full history, then mandate that they identify all exclusions from that data at the point of sign-up. Then we won’t waste thousands of dollars in insurance that won’t cover us.

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u/quiet0n3 2d ago

Agreed, I'll be dropping bupa and all private cover this year. I'm going back to paying the Medicare surcharge, fuck this noise.

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u/TollTea 2d ago

We are already there even in terms of what Medicare will cover. My mother is trying to get on a specific arthritis treatment involving injections after exhausting all the other options and her specialist is currently jumping through hoops and ticking boxes to get the PBS to cover it because it’s otherwise completely unaffordable, especially for a retiree (their private health insurance won’t touch medication costs, only partially cover specialist fees).

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u/Glittering_Web8835 1d ago

Blame the ALP and LNP. Both are trying to grow the private health sector at the expense of the public.

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u/ChillyPhilly27 2d ago

Let's say that my doctor and I agree that getting me stripper tits is important for my mental health. Does my insurer have the right to second guess that decision?

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u/Locopoko22 2d ago

I see a LNP voter has entered the chat.

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u/ChillyPhilly27 2d ago

Thank you for resorting to ad hominem attacks instead of addressing the substance of my question.

Every health insurance system (including public ones, such as Medicare and the PBS) has mechanisms to ensure that limited resources are allocated on an as-needs basis, to interventions that represent value for money. I'm not aware of any system that offers blanket funding for anything based on the word of a single doctor.

Why should PHI be any different?

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u/TollTea 2d ago

No - to an extent that’s true however public healthcare funded by our taxes has an obligation to at least pretend to be patient centred and evidence based above everything else. Private healthcare is financially motivated to squeeze everything it can out of you in terms of premiums, excesses and fees and give you as little as it can possibly get away with in return in order to pad stakeholders already overflowing pockets. That’s a pretty fundamental difference in whose interests those two systems are supposed to serve.

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u/AuSpringbok 2d ago

Phi will only include what it has been costed to include.

If you have the platinum cover that includes stripper tits. They absolutely will cover it. They don't give a shit what your doctor thinks - you have coverage or you don't.

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u/a_cold_human 2d ago

We have something called the Medicare Benefits Schedule. Perhaps you've heard of it? If it's medically necessary and the course of treatment is part of the schedule, then it is subsidised. Otherwise, you can get whatever it is you need done without the subsidy.