Questions on medical insurance answered

The world of health insurance can seem like a mysterious place to consultants who are new to private practice – and even those who aren’t. Bupa’s experts answer the questions doctors most commonly ask.

How do I begin treating insured patients?

Kris Martindale

Kris Martindale, Bupa’s head of clinician strategy, says: ‘You’ll need to apply for what we call “recognition”. This means that you can claim payment for treating the insurers’ customers. 

‘Most insurers will ask consultants for details of their training and qualifications, and proof that they hold appropriate indemnity insurance. You’ll need to take out separate indemnity insurance for your private work, as this isn’t covered by your NHS indemnity.’

How can I promote my new private practice?

‘Aside from making the most of networking opportunities with local GPs, I’d recommend making the most of online directories,’ advises Mr Martindale. 

‘At Bupa, our directory Finder receives more than 100,000 visits a week, so it’s a great place to showcase your practice. 

‘We encourage our customers to take a look at consultants’ Finder profiles before deciding who to see. We know that profiles with a photo get more visits than those without, and the more information you can share about your skills and expertise the better.’

How do I invoice for delivering private care?

Mr Martindale says: ‘We want to make sure the consultants we work with are paid quickly, correctly and efficiently, so we ask them to invoice us electronically within six months of carrying out any consultations, tests or treatment. 

‘Like most insurers, we offer a number of ways to do this. One way is using our free Providers Online website. 

‘We create a consultant’s own Providers Online account when they become Bupa recognised and they can also use this to view pre-authorisations, pre-populate invoice details and track the progress of their accounts and when they will be paid.’

Find out more on page 20 of the Bupa Consultant Guide.

Civica Medical Billing

Why do I have to invoice for my patient’s care within a specific time-frame?

Mr Martindale responds: ‘At Bupa we expect doctors to invoice us within six months of delivering care. This is important because it gives us an up-to-date picture of their patients’ claims, so we can let them know their available allowances when they call about further treatment. 

‘It also means we can calculate renewal prices accurately, customers aren’t surprised by unexpected bills and consultants get paid quickly for treating them.’

What does health insurance cover?

Dr Robin Clark

Dr Robin Clark, medical director for Bupa Global and UK Insurance, says: ‘Health insurance is designed to cover the cost of acute conditions. The Association of British Insurers (ABI) defines an acute condition as a disease, illness or injury that is expected to respond quickly to treatment which aims to return the patient to their previous state of health. 

‘Health insurance covers the cost of medically necessary, planned private consultations, tests and treatment for these conditions.’

What about chronic conditions?

Dr Tim Woodman

Dr Tim Woodman, Bupa’s medical director, policy and cancer services, told Independent Practitioner Today: ‘Most health insurance doesn’t usually cover treatment and care of chronic or long-term conditions. We use the ABI definition of chronic conditions. 

‘This is a disease, illness or injury which has one or more of the following characteristics: 

  • It needs ongoing or long-term monitoring through consultations, examinations, check-ups and/or tests; 
  • It needs ongoing or long-term control or relief of symptoms; 
  • It requires rehabilitation or for you to be specially trained to cope with it; 
  • It continues indefinitely; 
  • It has no known cure; 
  • It comes back or is likely to come back.

‘Bupa patients may have cover for diagnosis and some tests if they’re unwell. However, once a chronic condition is diagnosed, cover for it is no longer available. They’ll need to be referred to their GP and the NHS for the ongoing management, screening and monitoring of the condition. Or they may decide to self-pay for private treatment. 

‘If a Bupa patient has an unexpected acute flare-up of a chronic condition, a short course of treatment that can modify or cure the symptoms may be covered. 

‘Treatment is covered when the condition is likely to respond quickly and the treatment aims to restore them to their previous level of health immediately before the acute flare-up. 

‘After this, the patient would need to be referred to the NHS for the ongoing management of their condition, as health insurance cover isn’t available for this, or they may decide to self-pay for private treatment.’ 

What is an outpatient allowance ?

Dr Woodman explains: ‘An outpatient allowance covers tests like X-rays, consultations with a specialist surgeon or doctor and therapies like physiotherapy. 

‘Patients can choose to have out-patient allowances of £500, £750 or £1,000 to help reduce their monthly premiums. Once patients have used their outpatient allowance, they need to pay for further private appointments themselves.’

How do insurers’ hospital networks work?

Mr Martindale says: ‘Most health insurance policies cover patients to be treated at hospitals and clinics in their chosen hospital network by healthcare professionals recognised by their insurer. 

‘Bupa offers patients a range of hospital networks. For example, depending on where they live, they may choose a smaller network or to exclude central London hospitals if they’re looking to reduce their premium. 

‘We also have specific hospital networks for some services that are covered by our health insurance policies, such as cataract treatment, MRI and CT scans, to make sure that they meet our quality standards for these services. 

‘The agreements we have with hospitals and clinics offering these services are separate to our main agreement.’

How do I know what the insurer is covering for my patient?

‘Patients should call their health insurer to authorise any consultants’ tests or treatment before they begin,’ advises Dr Woodman.

‘Pre-authorisation lets the patient, and you, know that the care the patient needs is covered by their health insurance policy. This is especially important if the patient’s policy doesn’t cover a specific condition the patient may have; for example, a pre-existing condition that their insurer is unable to cover. 

‘Once a test or treatment is authorised, Bupa will give the patient a pre-authorisation number, which you should use when invoicing for that test or treatment.’

Consultants treating Bupa patients can use Bupa’s Providers Online website to check what has been pre-authorised for their patients. More details on how to do this can be found on page 12 of the Bupa Consultant Guide.

What does ‘fee assured’ or ‘fee approved’ mean?

‘It is what some insurers call consultants who charge within their benefit limits’, says Mr Martindale. ‘It’s important because it means we can reassure Bupa patients won’t receive extra bills for their treatment, as long as it’s covered by their policy.’

What happens if a patient’s surgery is more complicated than originally expected and takes longer than usual?

Dr Woodman says: ‘Most insurers have a list of industry standard surgical and medical services that’s updated monthly, However this can’t address every potential medical situation for all patients so that’s where our surgical fee uplift process comes in. 

‘Consultants can request an uplift where a procedure is more complex and may take significantly longer than indicated in the Bupa Schedule of Procedures or more than one consultant operates on a patient during the same theatre session – known as two-handed or multiple-handed surgery.’

To find out more about Bupa’s surgical fee uplift process, visit page 16 of the Bupa Consultant Guide.

Where do you stand on experimental medicine?

Dr Woodman answers: ‘Our policies cover treatments that are consistent with generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, duration and the hospital, clinic or location where the services are provided; and demonstrated through scientific evidence to be effective in improving health outcomes.

‘We want to give our customers with cancer fast access to breakthrough drugs and treatment. Our policies cover chemotherapy and advanced therapies – for example, gene therapy medicines, somatic-cell therapy medicines and tissue-engineered medicines. 

‘They may cover cancer drugs or treatment if there is good evidence to support their use, even if the treatment does not have NHS approval. 

‘We welcome consultants calling us to find out if the cancer drug therapy they’re proposing to use is covered by the patient’s policy.’