Bupa Insurance "Open Referral" and Reimbursement Cutbacks to Patients. May 2012.

BUPA OPEN REFERRAL MAY 2012

The new Bupa "Open Referral" scheme applies for subscribers who are in the Bupa Corporate Select Scheme and it would seem increasingly to personal subscribers. Under this system the GP has to refer the patient to the insurer and must give some indication about the clinical problem. At pre-authorisation the patient is then offered the names of one or two other consultants who are on the Bupa Fee Assured Scheme or in a Partnership agreement with Bupa.

Bupa claim to have quality information which will guide them in making these choices for the patient but also admit that this is a cost driven exercise and that they are trying to contain expenditure. In claiming a "quality" aspect to their redirection of patients Bupa is flying in the face of the recent OFT report which stated that the private medical insurers do NOT have quality information about individual consultants.

Despite various claims that open referrals may occur in up to 40% of cases (i.e. the patient or GP does not have a named consultant) the evidence from all the insurers to the OFT is summarized in the OFT report in April 2012 which stated that 9 out of 10 GP referrals were in fact to a named consultant (Footnote Page 74).

The professional view is that the GP to consultant referral pathway should be the basic route towards specialist care. This stance which has the backing of the major Royal Colleges, Specialist Associations, GMC and the Patients Association has been expressed in the FIPO Charter. The patients' view has been encapsulated again recently in a ComRes report which supports the contention that the majority patients wish to have a GP referral to a named consultant. ComRes is an entirely independent company which recently surveyed over 2,000 patients. This showed that 74% of patients preferred their GP to advise on their choice of consultant as opposed to an insurance company.

Thus, this new Bupa approach of selecting the patients' consultant is not backed by any evidence of a general patient acceptance and in fact many patients are complaining about the process.

Click here for the FIPO Charter…

For details of the ComRes report click here…

 

BUPA REIMBURSEMENT CUTBACKS TO PATIENTS MAY 2012

The principles behind the relationship between consultants and patients in the independent sector are clear and laid out in the FIPO Charter. Consultants charge patients fees and have a contract with patients who are responsible for their oen fees. Insurers make payments to patients to help cover these fees i.e. the patient receives insurance benefits or reimbursements. These reimbursements may be affected by specific individual exclusions or excesses depending on the patient's contract with the insurer. Patients are entitled to an estimate of fees which can be given by consultants in many (but not all) circumstances.

If the insurance benefits do not cover the full fee then the patient is liable for this shortfall and must pay a top-up fee. Overall the vast majority of consultants will charge within traditional benefit rates and so the patient has no short fall to meet. Insurance reimbursements to patients do vary slightly between different insurance companies but nevertheless evidence gathered by FIPO indicates that the number of shortfalls reported by the other main insurers (excluding Bupa) for consultants' fees ranges from just over virtually zero to 3%.

Commencing in 2012 Bupa Insurance has now cut back on benefits that patients may receive for various procedures in a number of specialties. The Bupa cutbacks in patient reimbursements have been challenged by the profession as they come on top of a failure by Bupa to raise the reimbursements for patients by any significant amount over the last 18 years. These cutbacks (without any specified reduction in premiums paid by the patient or corporate clients) will mean that many Bupa subscribers will face increased shortfalls or alternatively a loss of choice if Bupa refers them to a limited number of consultants who are locked in to a "fee assured" contract with Bupa. It should be appreciated that this may also mean that patients may lose their first choice of hospital.

An initial analysis in May 2012 by FIPO of several major specialties affected by Bupa's actions (ENT, GI endoscopy, plastic surgery/dermatology, urology, gynaecology and orthopaedic surgery) has noted that in some 39 commonly performed procedures there has been an average cutback of reimbursements by 32% amounting to on average £213. The range of reimbursement reductions ranges from 5% to over 50% in some cases. Bupa has raised the benefits for a smaller number of procedures which are less commonly performed. Since that date Bupa has cutback in other specialties such as abdominal surgery and is refusing to reimburse for various local anaesthetic injections which were part of previous normal charges and reimbursements.

In addition Bupa has also cutback reimbursements for a number of out patient diagnostic procedures in cardiology, audiology and ophthalmology. In these not only have the previous reimbursements for consultant fees have been cut but the equipment charge (i.e. a diagnostic ultrasound machine used to look at the heart) has now been bundled in to one charge along with the consultant's fee benefit. This means that the Bupa new low benefit must encompass all equipment, consumables and other costs associated with providing the service. The situation is confused by the fact that these tests are often performed on hospital equipment and hospitals have separate contracts with Bupa. If the equipment is supplied or owned by the consultant then these new benefits will be incorporated with the consultant's fee but the level of reimbursement is insufficient to purchase and maintain this type of diagnostic equipment. Bupa have stated that consultants who fail to comply with the Bupa schedule (i.e. charge at the new rates dictated by the insurer) will not be recognised to perform this range of tests. This may have an adverse effect on the patient's clinical management and continuity of care.

In addition Bupa has now announced that it will only pay for Caesarian sections when the mother's life is at risk. This has causes some concern although Bupa claim they are merely enforcing their normal rules.

The response to the Bupa actions of removing choice and simultaneously cutting reimbursements for many procedures has caused some reaction.

Patient comments under the title "BUPA insurance - really value for money?" (Note this is NOT a FIPO website nor has FIPO contributed to this)…

The Private Patients' Forum views

The Daily Mail article about Bupa and Caesarian section

FIPO press release about Bupa and Caesarian sections

For details of the FIPO Surveys, Newsletters and the Patient leaflet click here…