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
How we set and agrees fees
How we review procedures
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
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.
What to do if you think the complexity grade of a procedure needs updating 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.
What to do if you think a code needs changing or a new one should be added What to do if you think a code needs changing or a new one should be added