Specialist fee guidelines & medical insurance: Know your rights

When you purchase a medical insurance policy, you’re buying the peace of mind that you’ll be covered for the full cost of your treatment and hospital stays in the comfort of a private facility. Many policyholders believe this means everything is included under the policy and there are no extra costs of pay, but unfortunately this isn’t true in all cases. You may find that your insurance doesn’t cover you for the full cost of your specialists fees, leaving you with a considerable shortfall to pay.

Most policyholders are unaware that insurers operate to strict fee guidelines. They purchase policies expecting everything to be included and are understandably shocked when this isn’t the case. Your insurer won’t tell you about fee guidelines when they’re trying to sell you the policy, so it’s important to be aware of the additional costs you may be incurring when you take out a private medical insurance policy.

What are fee guidelines?

  • All medical insurance companies operate to a set of fee guidelines regarding the payment of hospital specialists. For every medical procedure there is a corresponding procedure code with a maximum price allocated to it.

  • Specialists can choose to adhere to a particular insurance companies fee guidelines or operate to their own scale of charges. If they have their own pricing structure it could mean for some or all procedures they charge more than your insurer is willing to pay.

  • Each insurer has a different set of fee guidelines, so the maximum Aviva would pay for a procedure may be different from the figure used by BUPA or PruHealth.

  • Fee guidelines are regularly updated to reflect rising prices and costs of treatment, although it is argued that insurers in some cases charge well under the market rate.

  • Generally the fee guidelines are based on an average price for the procedure, so if you’re using a London specialist or a particular expert in their field then this figure may not cover their costs in full.

Will I have to pay any extra charges?

It depends – some policies such as large company schemes have additional perks where if a specialist charges above the fee guidelines your insurer will still pay this in full. Often if this isn’t the case you’ll find your employer willing to pick up the tab for any additional costs.

Unfortunately individual policies aren’t so lucky and if you decide to use a specialist who charges beyond your insurers fees, then you’ll have to pay any additional costs.

It’s worth noting that sometimes specialists are willing to adhere to your insurers fee requirements on individual cases, so it’s always worth asking your specialist.

Will I know any additional costs upfront?

Yes – when you give your insurer the details of your specialist they should advise you if they can charge beyond the fee guidelines. You will be covered for the cost of a consultation in full, the charges will only apply when you have actual treatment involving a procedure code. You’ll need this code beforehand to get the procedure approved by your insurer. Your claims assessor will be able to find out what your specialist is charging for this procedure and let you know if any shortfall are applicable. This gives you time to decide whether you want to go ahead or not with this specialist.

Can I change specialists?

Yes – You should know in advance whether your specialist charges beyond your insurers guidelines on not. In some cases this could be less that £10 and easily affordable, but when it’s not you can ask your insurer to change specialists. Your insurance company should provide you with cover for a consultation with a new specialist of your choice. Just make sure you check they adhere to the fee guidelines so you don’t get any more surprises. You can change specialists at any point. Just because you’ve had a procedure previously with the same specialist doesn’t mean you need to use them again.

If my specialist charges higher fees does that mean he’s more highly qualified?

Not necessarily – All specialists have the right to charge the prices they see fit. Some specialists charge more because they’re working to a different insurers fee guidelines, while others may feel their work deserves a special London weighting. Of course world leading specialists will often charge way beyond your insurers fee guidelines, but most of the time the price you pay isn’t indicative of the quality of the specialist.

Remember all private specialists are fully qualified and available on the NHS, often the prices they charge are nothing more than personal preference.

Fee guidelines can be worrying for policyholders, but your insurer will always be able to tell you any additional charges in advance, so you won’t find yourself with unexpected bills to pay. Remember, if you can’t afford to pay a shortfall don’t feel pressured to do so, change specialists to one who operates within your insurers guidelines.

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