The ethics debate: Should specialists have a fee cap?

In recent years there has been heated debate surrounding the price of specialist fees for private patients. While all specialists hold an NHS post, private work is where specialists generally earn majority of their income. With no cap on the fees they are able to charge, it is often felt the fees commanded by many private specialists are excessive. In turn this is impacting on the insurance sector in a number of ways:

  • Cost – Increases in the price of insurance premiums in order to absorb these additional costs.

  • Tightened policy terms – The growth of ERF (exceeding recommended fees) clauses in policies, whereby the insurance company will only pay out up to a recommended fee, leaving the policy holder to cover any further shortfall.

  • Increased bureaucracy – A push by insurers to make agreements with specialists to abide by fee guidelines. While some specialist are willing to agree to sign up fee guidelines, this can be confusing, with each insurer in turn operating a separate set of guidelines. Ultimately this means a specialist operating to BUPA guidelines may still charge more than the Aviva guidelines, and visa-versa, leaving a complicated system of charges which is often difficult to understand.

Specialists themselves have stood by their right to charge to their own fee structure. They argue that with increasing experience and knowledge their work becomes more valuable, and that if some patients do not want to pay these prices, there are plenty of others who will. On the other side of the debate, insurers argue that they are the ones picking up the hefty fees, which impacts upon the private sector through increasing premiums.

Sadly, issues with specialist fees don’t end with pricing alone, in fact many insurance companies have set up their own departments tackling fraudulent bills from specialist. In order to understand this problem it’s necessary to look at the billing process in a little more detail.

How do specialists charge for their services?

  • Every medical procedure has a corresponding procedure code attached to it.

  • These procedure codes are universal across the medical sector and for each code a specialist will charge a set fee of their choice.

  • Procedure codes normally comprise of a letter followed by 4 numbers. Just for reference an example of a procedure code is G6500, in this case a diagnostic gastroscopy.

  • As some procedures are more complex and require more time than others, some codes demand higher fees. This is universally accepted by insurers, as understandably a coronary bypass procedure is much more complex than a haemorrhoidectomy.

Issues with code combinations

In some surgeries more than one procedure is carried out at the same time. Usually this is to prevent the patient from undergoing the stress of two separate surgeries and generally saves time and money. For surgeries such as this the specialist will either bill under two separate codes, or use a single combination code, where the two surgeries are commonly used together. Code combinations are of a lesser value than individual procedures, as procedures which can be combined have less work involved and can be completed more quickly.

Recently insurers are becoming aware of a significant problem, whereby a small number of specialists are billing under individual codes so as to fraudulently receive higher fees for multiple procedures which should rightly be combined. This has let to the growth of code combination departments in major insurance companies. The process for detecting this has become increasingly sophisticated. Individual codes which should be combined have been programmed into the claims computer software so the problem is highlighted as soon as possible. As a rule customers are never told of any billing issues, but it could mean it takes little longer for your claim to be authorised.

Additional cosmetic procedures

As you’re probably aware, your private medical insurance won't cover you for any procedures which are cosmetic. In an attempt to get around this and charge higher fees a minority of specialists are incorporating cosmetic procedures under the guise of genuine medical treatments. For example, in the past hernia operations have been combined with a tummy tuck for cosmetic reasons. While insurers are becoming increasingly aware and mindful of these tactics, they are still a problem today with fraud teams ever on the look out for suspicious activity.


It’s important to stress that the majority of specialists operate in a completely legitimate manner. If your specialist charges seemingly high fees, this is perfectly legal and not a cause for concern. As with any industry there are always a few bad eggs who try to scam the system for all they can get, but insurance companies are working closely with the general medical council to make these happenings a thing of the past. Remember, if you’re unhappy or concerned regarding any aspect of your specialists treatment, be sure to get in touch with your insurer. They will be able to provide guidance regarding changing your specialist, and point you in the right direction for any complaints procedures you can access.

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