Health Insurance – Reasonable Fees

Introduction

This document sets out what We would expect specialists and practitioners to charge for the services they provide to patients. We will pay eligible fees in full (subject to the benefits shown in Your policy documentation) when a specialist or practitioner charges up to the level shown within this document for treatment that they have provided; no payments will be made for supervision of services provided by others.

All services claimed for must be listed in the Schedule of Reasonable Fees. If the required treatment is not listed in the Schedule of Reasonable Fees, please contact us prior to receiving treatment so that we may confirm our position.

From time to time, certain specialists’ and practitioners’ fees exceed this limit. The specialists’ and practitioners’ charges that we reimburse will always be limited to the level shown in the Schedule of Reasonable Fees and any excess charge over this amount will not be reimbursed. For this reason, it is important that you always pre-authorise your Treatment with Us to understand the full extent of coverage.

In all instances specialists or clinical and complementary practitioners must work within their scope of practice and in line with their professional codes of conduct. Any new procedures that are not routinely undertaken within their routine practice must be considered and agreed by Us in advance.

Billing Principles

Procedure Code Queries

If the medical provider is unsure how to code for a specific procedure then they can ask us to advise what code they should use. To determine what the appropriate representative code is we will require a medical report written by the specialist, detailing what is planned to take place during the treatment so that we can identify the most appropriate code for the planned treatment. We will select the most appropriate code in line with treatment and procedures listed on https://www.ccsd.org.uk/ccsdschedule.

Procedure Fees

The specialist/surgeon/practitioner fee for a procedure includes all integral parts of that procedure including preoperative assessment, the procedure itself and all routine aftercare including out-patient consultation for at least the first ten days.

Injections

We do not accept separate charges for giving sub-cutaneous, intramuscular or intravenous injections (or vaccinations where eligible) as on their own these are not deemed to be separate surgical procedures and any charge for giving injections is covered by the standard consultation charge.

Coding

Invoices must be coded using the industry standard CCSD code for the procedure as listed in this Schedule. This code should only be used for the use set out in the standard description. If a code states ‘as sole procedure’ in its narrative it should not be performed in addition to another procedure. If any procedure is undertaken which is not coded, specialists should contact Us with a detailed report outlining what is being done and a breakdown of the proposed cost so that we can identify the most appropriate code to be used or the most appropriate level of reimbursement for the planned treatment.

Unbundling

The component parts of single procedures or services must not be itemised out and billed as if they were separate or additional services. As a guide, there is no clinical intervention which should routinely need more than one code.

We will not reimburse additional charges for component parts of single procedures and may refuse to cover fees from providers who persistently unbundle charges. Unbundling includes:

1. Charging for two procedures where one is part and parcel of the other or is so frequently performed that it is in effect part and parcel.

2. Charging for in-patient care or ITU care where this is simply routine post-operative care.

3. Charging for pre-operative assessment or post-operative analgesia including nerve blocks.

4. Using procedure combinations whose primary purpose is to increase reimbursement. An example of this would be charging for wound infiltration with local anaesthesia.

5. Charging for anaesthetic when anaesthetic services have also been provided by an anaesthetist.

Multiple Procedures

Different insurance companies have different rules about fees for multiple procedures. Where more than one procedure is performed at the same time we will pay the following fees:

1. 125% of the highest procedure fee in the case of two concurrent procedures; and

2. 140% of the highest procedure fee in the case of three or more concurrent procedures.

Only in the most exceptional circumstances and on a case-by-case basis discussed prior to any treatment taking place will further procedures be considered for additional reimbursement.

Multiple Specialists

Where two or more specialists operate on a member as a matter of preference, only a single fee is claimable.

Where two specialists perform different procedures and where the second procedure cannot be performed by a single specialist, then the two specialists will be treated separately for the purposes of this fee schedule. These requests must be preauthorised and will be considered on a case by case basis. In this case, a detailed report will be required that clearly explains the medical need for additional specialists to be present, the procedure codes, the estimated time in theatre and requested fees (for each specialist) so that we may determine the appropriate level of reimbursement required.

Consultation Charges

A consultation means a face-to-face consultation only. Only a single consultation may be claimed on any one day, consultation fees are set regardless of time or complexity. We do not provide benefit for consultations using electronic communication for example by email, telephone or across the internet. We are also unable to cover clinic fees, waiting room fees, consultation room fees and other similar charges.

In-Patient care charges are claimable only by the Physician in charge of the case and are for face-to-face visits and are not claimable for being on-call. Other specialists may claim benefit for specific consultations for specific problems only, but this should be pre-authorised. We consider out-patient follow-up within ten days of a surgical procedure to be an integral part of post-operative care and thus to be covered by the charge for the procedure and this would not be reimbursed as an extra service.

Anaesthetic Fees

The benefit for anaesthesia includes an amount for pre-operative assessment (whether on the ward or at a clinic), the anaesthetic itself including any lines or monitoring and post-operative care including analgesia, care in ITU or HDU, nerve blockage, neuroaxial blockade or epidural. None of these should be listed as extra. Operations should be coded using the single CCSD code which describes the operation performed plus all its component parts. Additional codes should only be used for genuine separate and additional procedures.

Anaesthesia administered by the Surgeon

In certain cases, a Surgeon may administer anaesthesia which would otherwise be administered by an Anaesthetist. In this case, subject to preauthorisation, We may be able to offer an additional benefit for this.

All Inclusive Fee Packages

Occassionally, specialists’ fees are included within the prices we have agreed with the hospitals, notably diagnostic radiology, pathology and in-patient therapies. In these circumstances specialists should negotiate remuneration for their services with the hospital or clinic. This arrangement provides clarity and reassurance for patients that all charges associated with such services are covered under our contract with the hospital.

Facility, Consumable and Equipment Charges

Charges may be made for facilities provided there is a formal agreement in place between the facility and Laferla Insurance Agency Limited. Consumable items (including drug costs) and equipment charges should be invoiced to Laferla Insurance Agency Limited under the agreement of the facility unless there has been a prior arrangement made directly with Us. No charges should be made for any item which is not subject to a formal agreement.

Effective and Appropriate Medical Treatment

We do not provide benefit for experimental or unproven procedures, including those using new technology or drugs, where safety and effectiveness have not been established or generally accepted. Please contact us before undertaking treatment which might fall into this category. Under no circumstances should codes intended for existing procedures be used for new and as yet uncoded procedures.