Consultant fees explained

When we carry out a complexity review, we use the CCSD procedure groups and review each specialty individually. Bupa’s doctors compare procedures against each other to identify those that are graded out of line with other, similarly complex, procedures. This creates a list of procedures for further in depth clinical review.

Then we check each procedure code to see whether the procedure has significantly changed over time, whether the existing narrative for the code still accurately describes the work carried out, and whether the existing complexity rating for the code is too high or low. The review may also identify new procedures that need codes requested from CCSD and then added to the Bupa Schedule of Procedures. As a result, we may propose either a completely new code and narrative for a procedure, a narrative change, or a change in the reimbursement level.

We also take into account feedback and comments from Bupa recognised consultants and other providers. For example, several consultants mentioned to us that cataract procedures previously carried significantly higher reimbursement compared to other procedures of similar complexity.

We then ask an international panel of independent practising clinicians, with no possible conflict of interest in the relevant specialty to examine the narrative and describe the complexity of each procedure in more detail. This examination focuses on:

• the level of skill and training required (and, if appropriate, the grade of NHS doctor) to safely perform the procedure
• the level of clinical risk and recognised perioperative mortality and morbidity
• the rarity of the procedure
• the care setting
• other complicating factors (for example, complex intra-operative diagnostics or specialist post-operative care)
• the duration of surgery

This panel then compares the procedure with others in the same specialty, and also with procedures of similar complexity in different specialties, and applies a provisional complexity grade. We then ask leading independent UK specialists to review the provisional complexity grades based on their own experience and NHS practice, to ensure that the provisional complexity grades are reasonable.

We review any feedback, make final changes based on it and, once approved by one of Bupa’s medical directors, publish any complexity changes. As a result of these changes, the reimbursement rates for the affected procedures may increase or decrease to bring them back into line with procedures of a similar complexity. Each year only a minority of procedures will change rating. Of the several thousand different procedures Bupa funds, since 2012 we increased or decreased consultant reimbursement for around 300 procedures, reviewed and revised or added around 220 drugs and treatments to our funding policy and added 224 new procedure codes to the Bupa Schedule of Procedures.

If you think a procedure in the Bupa Schedule of Procedures is incorrectly classified, please write to us explaining the rationale for your view including supporting clinical evidence. For example, how the particular procedure compares to other similarly classified ones in terms of complexity, time taken and the level of skill required by the operator.

Our Policy Team will review all requests for reclassification and where the evidence supports a classification review, this will be considered by a Bupa Medical Director who will seek input from independent practising clinicians in the relevant specialty who have no conflict of interest.