How we calculate reimbursements
We reimburse our recognised consultants and anaesthetists for the treatment they deliver to our customers based on the complexity, time and skill required to perform a procedure. We publish an extensive list of procedures and complexity codes in our Schedule of Procedures and the rates up to which recognised consultants and anaesthetists can claim – these are known as Bupa Benefit Maxima.
Here you’ll find out:
- What you can charge for
- How we set and agree our fees
- How we review procedures
What can consultants charge for
- Eligible treatment is that of an acute condition, together with the products and equipment used as part of the treatment, that:
- is consistent with generally accepted standards of medical practice and representative of best practices in the medical profession in the UK
- is clinically appropriate in terms of type, frequency, extent, duration and the facility or location where the services are provided
- is demonstrated through scientific evidence to be effective in improving health outcomes
- is not provided or used primarily for the expediency of the patient or their consultant or other healthcare professional
- Consultants are responsible for making sure that all care is relevant and that they have the professional capability and training to deliver the care.
- Our customers are responsible for making sure that the treatment, services or charges are covered under their scheme and not excluded under their benefits.
- Some Bupa recognised consultants can also charge for other services, so long as they have a specific agreement with Bupa to do this. Examples of these services are:
- diagnostic tests which are published in our Schedule of Diagnostic Tests - and are performed by consultants using their own equipment in an out-patient clinic or consulting rooms. Learn more about our out-patient diagnostic test (OPDT) agreement.
- telephone and video consultations
- We’re unable to accept invoices for these services from consultants without the specific agreement.
- Consultants who aren't recognised by us are not eligible for reimbursement by us for treating our customers
- Consultants and anaesthetists need to charge us in line with the billing rules found in the essential notes of our Schedule of Procedures.
How we set and agrees fees
We agree out-patient consultation fees with consultants individually. We always consider the fees that are charged by other consultants who’ve recently been recognised by us. These fees reflect the differing nature of the services they provide. For example, consultant psychiatrists deliver the majority of care during out-patient consultations whereas a surgeon will deliver care in a range of settings, so we offer slightly different fees based on these differences.
In rare cases we may have to remove our recognition if a consultant charges fees that are out of line with their peers with no justification. Our customers expect us to manage fees on their behalf - in a survey we carried out in 2015, three quarters of our customers said they expect their health insurer to ensure high quality care is delivered and that costs are managed. Many members have out-patient benefit limits, often around £1,000 per year, and when these are reached they must pay for all consultation fees above their benefit limits themselves.
Procedure feesWe set the fee levels, and surgical and anaesthetic benefit limits for all procedures in our Schedule of Procedures. We do this to ensure fair reimbursement for consultants and help to keep health insurance affordable for our customers. For more information on how we do this please read below.
Diagnostics are normally provided and billed for by hospitals and facilities, however consultants can provide these services as well. If you’d like to provide these services you’ll need a separate agreement with us, which sets out the services offered and the fees we’ve agreed for them. The fees for these services will be based on the fees charged by other providers offering the same service.
Our Schedule of Diagnostic Tests lists all the tests that you can invoice for, so long as you perform them yourself in your consulting room using equipment that you have purchased and maintained. They’re marked with “OPDT” under the procedure code. Unfortunately we’re unable to reimburse consultants for these tests if they don’t have an agreement with us for providing them.
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Code identification
Each procedure in our Schedule of Procedures has an individual code to identify it. We use industry standard procedure codes developed by the Clinical Coding and Schedule Development Group (CCSD). The CCSD produces guidance to allow accurate coding of clinical activity in independent healthcare, and its codes reflect current medical practice in independent healthcare. The CCSD groups procedures by anatomy or procedure type, and allocates them to the clinical specialty that performs them most frequently. -
Clinical rationale
We reimburse our recognised consultants and anaesthetists for the treatment they deliver to our customers based on the complexity, time and skill required to perform a procedure. We make sure that these codes are up-to-date by carrying out a complexity review, using the CCSD procedure groups and reviewing each specialty individually. Our doctors compare procedures against each other to identify those that are graded out of line with other, similarly complex procedures. This gives us 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 for which we need to request codes from CCSD, so that we can add them to our Schedule of Procedures. As a result of this review, we may propose either a completely new code and narrative for a procedure, a narrative change, or a change in the reimbursement level.
To avoid any possible conflict of interest, we ask an international panel of independent practising clinicians in the relevant specialty to examine the narrative and describe the complexity of each procedure in more detail. Their 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
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Review the evidence
The panel of independent clinicians 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.
In carrying out our review, we’ll also seek feedback and comments from our recognised consultants, specialist professional organisations, and other providers in the speciality we’re looking at. For example, we looked at prostate biopsy codes after several consultants mentioned to us that the two existing codes didn’t reflect new developments in diagnostics. We worked with them to refine one of the narratives and develop narratives for three more codes to more accurately represent modern diagnostics and ensure that consultants were fairly reimbursed for the new, more complex tests.
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Finalise and publish
Then we review the feedback from our recognised consultants, make final changes to our proposals based on it and, once approved by one of our 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 we fund, since 2012 we increased or decreased consultant reimbursement for 412 procedures, added 44 drugs to our funding policy and added 210 new procedure codes to our Schedule of Procedures. -
What to do if you think the complexity grade of a procedure needs updating
If you think the complexity grade of a procedure in our Schedule of Procedures should be reviewed, please write to us explaining the rationale for your view and 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.
We review all these requests and, where the evidence supports a update, this will be considered by one of our medical directors, who will seek input from independent practising clinicians in the relevant specialty who have no conflict of interest.
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What to do if you think a code needs changing or a new one should be added
Clinical Coding and Schedule Development Group (CCSD) sets the standard procedure and diagnostic test codes for the UK private healthcare sector. It welcomes requests to change codes/add new codes via the “Schedule amendments” section of its website because it helps to keep the codes up-to-date. Requests are discussed each month and once CCSD has made a change, it’s up to each insurer to adopt it. We aim to adopt all changes within a month of CCSD’s decision.
Consultant recognition
How to get in touch
0345 755 3333 ^
