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Insurance Claims Guidance for Consultants

Revised January 2016

Important information to ensure that the professional fees charged are fair.

It is an absolute condition of your professional recognition by WPA that you will provide your patients with written details of your fees in advance of treatment taking place.

In the event that a patient is not reasonably advised of fees (in writing), and there is a shortfall they have not agreed to, WPA reserves our rights to support the patient in resisting demands for any additional payment. In addition, WPA reserves the right to withdraw recognition from any provider in these circumstances.

Introduction
The WPA Schedule of Benefits has been produced for the use of consultant specialists and for policyholders (our customers), on whose behalf we reimburse treatment costs within the terms of their policy. It is made freely available in the interests of transparency and Treating Customers Fairly.

WPA recognises the importance of freedom of choice for patients to see the consultant of their choice and for the consultant to treat the patient in the hospital of their choice in order to ensure that the best medical resources and patient care are provided.

The contract for clinical service exists between the practitioner and the patient, not between the practitioner and WPA. However, settlement of fees may be made directly by WPA to the practitioner, for and on behalf of our customers.

It is WPA´s goal to reimburse customary & reasonable fees in full within the terms of our customers´ policy and the WPA Schedule of Benefits.

This Guidance for Consultants also applies to WPA Protocol Plc, a wholly owned subsidiary of WPA, which administers Corporate Health Care Trusts (CHTs), on behalf of many large corporate healthcare schemes.
General rules
Our schedule uses the codes and narrative description for each procedure as have been developed objectively by the Clinical Coding and Schedule Development group (CCSD).

The benefit levels for each procedure are regularly reviewed by WPA´s Medical Advisory and Clinical Governance Committee, whose medical members have both private and NHS consultant experience. We take professional advice from our specialist advisers and through continuing dialogue with both the medical profession and professional specialist bodies. Benefit levels are set to reflect the complexity of a procedure, the time and skill involved in its performance and that which is customary and reasonable and a fair return for the service rendered.

The benefit levels include the routine pre-operative and post-operative care appropriate to the procedure and any required post-operative out-patient consultation following day case surgery.

The benefit levels indicated are intended to cover more complicated and time consuming operations as well as more straightforward ones - they should not therefore be considered the amount to be charged in all cases.

Consultants should, as part of their professional service to their patients, operate fair and consistent billing across their practice. It is our expectation that the level of fees charged for insured patients should be the same as for non-insured patients.

WPA does not seek to intervene in the clinical care of patients under specialist control. However, we may require further information from a specialist in order to determine whether the treatment being undertaken or proposed falls within the terms of the policy. Such information should be provided in a timely manner and appropriate detail.

In certain circumstances, it will be deemed reasonable for an extra fee to be settled when an appropriate explanation is received.

Our role as insurer is to indemnify our customers against treatment costs in accordance with the contract that prevails between us and the patient.

In turn, a contract exists between you and your patients.

This professional duty is documented by the GMC, the BMA and various professional bodies and can be found on the following links.

Good Medical Practice: Financial and commercial dealings (GMC)

Fee Arrangements for Patients in the Independent Sector

Voluntary code of practice for billing private patients (AAGBI).

and

Contract for private patients (BMA)


In the event that your pre-advised fees are greater than our level of reimbursement, then it is the policyholder´s duty to settle the difference.

It has come to the attention of the Competition and Markets Authority, that some customers with private medical insurance are being faced with significant shortfalls when presented with unexpected professional fees.

  • In the event that a patient is not reasonably advised of fees (in writing) in advance, and there is a shortfall that they have not agreed to, we reserve our rights to support the patient in resisting such demands.




Pre-authorisation
Policyholders and providers are strongly advised to seek pre-authorisation in order to avoid an unexpected shortfall.

In some cases pre-authorisation may have to be given in principle. The codes ultimately billed should represent the procedure actually undertaken notwithstanding any codes originally pre-authorised.

Subject to the validity of the information provided to us by our customer, the medical team and the hospital, we may confirm cover for a proposed treatment. However, we will still need to assess and certify any claim made under the policy before any payment can be made to you. In the event that subsequent information shows that the treatment fell outside of the terms of the healthcare scheme, WPA reserves the right to withdraw such cover and reverse any payments made.
Additional operative procedures & unbundling
Additional operative procedures

For those additional procedures carried out under the same anaesthetic.

Main operation 100% of the benefit for that procedure.
Second operative procedure 50% of the benefit for the relevant procedure code.

In exceptional circumstances and where justified by the specialist:

Third operative procedure 25% of the benefit for the relevant procedure code.

If the operator also provides local anaesthesia and/or sedation and post operative analgesia, code AC 100 can be used, but only when no anaesthetic fee is claimed by an attending anaesthetist.

In the event of uncertainty over which code to use, please contact WPA.

Unbundling

A single code is deemed to include those elements commonly performed as part of the main operation and without which the operation would be regarded as incomplete. No extra fee is chargeable for a surgical component of the main operation just because it has a stand-alone procedure code.

Guidance on combinations of codes considered unacceptable by CCSD can be found on www.ccsd.org.uk

Hospitals generally follow the codes used by the specialist in order to charge for their theatre fees. Errors in coding can therefore have a significant knock-on adverse financial effect, so it is essential that specialists take the utmost care to use the correct procedure code.

Anaesthetic benefit levels take into account all elements that constitute optimal care such as pre-operative assessment, the introduction of catheters, drains, monitoring lines, nerve blocks including epidural and local wound infiltration, post-operative analgesia and routine postoperative care.
Attendance fee benefit & multiple specialists
Attendance fee benefit

Routine pre and post-operative inpatient care is deemed to be included in the procedure benefit.

Attendance fee benefit during inpatient care of medical cases is payable to the admitting physician according to the severity of the illness of the patient up to the time of discharge or transfer to another specialist. This will only be considered for one primary specialist per day.

Additional consultation fee benefit may be payable to other specialists called in for specific medical problems.

Intensive care benefit is payable to recognised intensive care specialists on a daily basis to include the insertion of all lines, catheters and monitoring equipment. Procedure fee benefit or specialist´s consultation fee benefit will be payable in addition, when required for specific expertise in the care of the patient.

Intensive care will only be covered for a maximum of 28 days in any one year.

Multiple specialists

Assistant fee benefit is not payable for a procedure traditionally performed by a single well trained operator.

Where a procedure necessitates more than one discipline, and a second approved consultant specialist is required for best practice, WPA may consider a fee benefit supplement subject to pre-authorisation.

Anaesthetic and Surgical preoperative assessments

Routine arrangements should be in place to identify patients who have an increased risk of complications and morbidity/ mortality. For instance, early discussion between surgeon and anaesthetist after initial surgical consultation.

WPA expects that all patients will be assessed preoperatively by an anaesthetist. This may typically be on the day of surgery. The cost is included in our current fee structure for anaesthetists.

WPA does not routinely pay for separate preoperative consultations for any procedure although recognises that in certain circumstances it is necessary for a patient to been seen formally by an anaesthetist as a separate preoperative consultation.

WPA will only consider funding such a consultation if it has been pre-authorised by WPA following receipt of a detailed summary and risk assessment, and also that the cost of the consultation is made clear to the patient in advance.

Other services
Fees for other services such as prostheses, reporting of histopathology or diagnostic imaging are normally included in hospital charging tariffs agreed by WPA. Specialists should therefore check with the hospital before raising a separate, potentially duplicate, account for such items.

Fees for interpretation of test results such as ECGs, echocardiograms, pathology etc are deemed to be included within the benefit allowance for consultations and procedures.

WPA may consider reimbursement of charges for other items outside of the benefit levels within the schedule, but these should be pre-authorised in advance.
Insurance cover & shortfalls
Insurance cover

The level of insurance cover chosen by customers varies considerably and may not always be comprehensive. Many policyholders have an element of co-payment (Shared Responsibility) and may be personally liable for a significant proportions of fees charged.

All policies have certain exclusions and many are medically underwritten and have specific exclusions - pre-authorisation is therefore strongly advised.

WPA policies cover secondary specialist care of acute illnesses or injury following referral by the General Practitioner. They do not cover long term or chronic illnesses, rehabilitation, monitoring or maintenance of remission, or long term follow-up after surgical interventions.

WPA´s medical insurance policies are issued for one year´s cover and cover for acute illnesses or injuries - physiotherapy and follow-ups are therefore limited to one year.

Acute exacerbations of long term conditions may be covered.

There are specific conditions for cancer care.

For most claims, completion of a claim declaration is required by the GP or specialist to inform WPA of any relevant previous history which may influence the decision to provide or reject cover.

Referral from physiotherapists and opticians to specialists will be accepted, provided that the GP is kept fully informed.

Self referral by a patient would normally not be covered.

Shortfalls

If it is anticipated that a shortfall between the fees raised and the benefit level reimbursable is likely to occur, the provider has a duty of care to ensure that this is fully explained to the patient. This should be done at the earliest opportunity and before the treatment is undertaken as the patient would be responsible for the balance. We recommend that anaesthetists liaise closely with surgeons to ensure that their fees can also be made clear to patients at the earliest opportunity.

WPA does not seek to intervene in the clinical care of patients under specialist control. However, we may require further information from a specialist in order to determine whether the treatment being undertaken or proposed falls within the terms of the policy. Such information should be provided in a timely manner and appropriate detail.

In certain circumstances, it will be deemed reasonable for an extra fee to be settled when an appropriate explanation is received.

Our role as insurer is to indemnify our customers against treatment costs in accordance with the contract that prevails between us and the patient.

In turn, a contract exists between you and your patients.

It is your responsibility and your duty to your patients to advise them of your fees before the treatment takes place (except of course in the event of a formal emergency).

This professional duty is documented by the GMC, the BMA and various professional bodies and can be found on the following links.

Good Medical Practice: Financial and commercial dealings (GMC)

Fee Arrangements for Patients in the Independent Sector

Voluntary code of practice for billing private patients (AAGBI).

and

Contract for private patients (BMA)


In the event that your pre-advised fees are greater than our level of reimbursement, then it is the policyholder´s duty to settle the difference.

It has come to the attention of the Competition and Markets Authority, that some customers with private medical insurance are being faced with significant shortfalls when presented with unexpected professional fees.

  • In the event that a patient is not reasonably advised of fees (in writing) in advance, and there is a shortfall that they have not agreed to, we reserve our rights to support the patient in resisting such demands.
Specialist recognition
Policyholders will only be reimbursed for care from a specialist currently recognised by WPA. All such specialists must hold a current licence to practice and be on the Specialist Register of the GMC.

All consultants appointed by a properly constituted Consultant Advisory Appointment Committee to a consultant post and who are currently working in an NHS Trust will normally be recognised as a specialist.

Specialists currently practising in independent treatment centres or outside the NHS should apply individually for WPA specialist recognition giving details of their revalidation for GMC specialist registration, the hospitals to which they have been given practice privileges, their particular specialist skills and any publications or other credentials which they wish to be considered by the Medical Director.

WPA requires specialists to operate their private practice, billing arrangements and professional dealings with both WPA and our customers, fairly within the spirit of this Guidance for Consultants and good practice guidelines of the GMC.

WPA reserves the right to withdraw specialist recognition if it considers, for whatever reason, that a Specialist no longer adheres to these Guidance for Consultants criteria.