A war of words has broken out between the private practice representatives and a medical insurer over accusations that the latter is trying to force down consultant fees.
The Federation of Independent Practitioner Organisations (FIPO), which represents independent sector interests, is protesting about a new low fee schedule introduced by AXA PPP Healthcare.
A fixed ‘fee schedule’ has been applied by AXA PPP to all new consultants since 2008. Failure to accept the schedule means that some consultants are not recognised by the insurer.
But now, FIPO claims that AXA PPP is trying to force the new schedule on to established, experienced consultants.
It says patients referred by their GP to a preferred specialist may be told by AXA PPP that their consultant of choice could overcharge and they should see another, cheaper, ‘recommended’ consultant.
FIPO claims to have heard reports that patients who opted to see their first choice consultant have had their reimbursements reduced by anything up to 50%.
“We believe that this system could cause problems for some of the patients who may be moved by the insurer to a new consultant who has no knowledge of their case,” said FIPO chairman Mr Geoffrey Glazer.
“PPP is also targeting some anaesthetists, and again interfering with clinical matters, as the team work and understanding between surgeon and anaesthetist can be critical; no PPP clerk should be allowed to take this responsibility and thus interfere in these critical decisions. How can a clerk understand the specialist nature of the anaesthetic, the working relationship of the consultants or of the exact clinical reasons why a GP has suggested a referral to a specific consultant?”
But Dr Simon Peck, AXA PPP healthcare’s head of provider audit and information, retorted that FIPO had misunderstood the situation. Like all insurers they had a system in place to stop payment of excessive charges in order to keep health insurance premiums affordable.
“The vast majority of specialists - well over 90% - charge fees at a level we are happy to pay in full and it follows that the vast majority of our customers have their bills fully reimbursed. That will continue.
“We have always declined to pay bills from the small number of very high charging specialists in full, however, and the only thing that has changed is that we have now clarified, through publication of our schedule of procedures and fees, the amount that we will reimburse.”
FIPO has launched a survey of consultants to assess the extent of their concerns about their relationship with medical insurers.
Mr Richard Packard, FIPO deputy chairman, added: “Reducing patient choice through last minute financial pressures, when the patient is most anxious and in need of help, is interference in proper clinical practice.”
Tags: Fees, Private practice
This sort of problem has been looming for a number of years. One reason is that health ‘insurers’ have tended to take on the role of ‘healthcare providers’ with some doctors ’signing up’ to their terms and conditions. The basis of all private practice should be that the ‘contract’ is between the doctor and patient; and the patient can choose whether or not to have ‘cover’ provided by an insurer. The insurer has the right to state what (fees) they will cover and what they will not; if the doctor’s fee is ‘over the limit’ then the patient must pay any excess.
There are problems on both sides: the insurers have developed lists of their ‘approved’ specialists (rather than accepting the recognised ‘approval’ of specialist status by the profession); and some (few) specialists charge fees that are considered to be excessive, not only by insurers but by patients and other members of the profession
Apart from the contract between the private doctor and patient there is another more fundamental contract which the health insurers have been keen to disrupt. I am talking about the one between the referring General Practitioner and the Specialist. Patients rely on their General Practitioners referring them to Specialists whom they trust. Health Insurers are now taking it upon themselves to suggest alternative specialists to the patients, not based on their expertise as medical practitioners, but solely based on the prices they charge. Let’s be honest, the insurers care only about the bottom line and not about the quality of care their clients receive.
PPP have stated that whilst they have indeed introduced a fixed fee schedule which must be appled by new consultants “recognised” after 2008, this fee schedule will also apply as far as reimbursement is concerned for the patients of “capped” consultants. This penalises financially patients who either are existing patients of those consultants or who choose to go them. In other words there is adifferential reimbursement for patients dependoing which consultant they may choose to go to. Not surprisingly this change in the conditions which apply to PPP insured patients will interfere with choice and continuity of care and may result in inappropriate referral on cost not clinical grounds.