As a responsible commissioner of healthcare, our focus is on the interests of our customers, we are committed to help give them access to high quality, affordable healthcare. Our customers pay for doctors’ fees through their policies, so we work to make sure they pay a fair price.

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
Find out more

What can consultants charge for

All our recognised consultants can charge for consultations and procedures that are published in our Schedule of Procedures for our customers, so long as they’re within their respective specialty and are eligible under the customer’s policy.

How we set and agrees fees

How we review procedures

  • 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.
  • 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
  • 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.

  • 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.
  • 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.

  • 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.

How to get in touch

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