AXA PPP New Terms and Conditions and fixed Schedule of Fees for Consultants July 2008 for Consultants
AXA PPP has produced a fixed Schedule of Fees to which new and some established consultants must adhere, failing which PPP will not recognise their rights to treat any PPP subscribers. For the first time recognition by an insurer has been linked to a fixed fee schedule. Along with this are some new Terms and Conditions for consultants which are more stringent than the previous terms.
This has to be considered against the backdrop of normal consultant practice in the independent sector.
The Historical Basis of Independent Consultant Practice
Independent specialist practice (secondary care) in the UK has always been consultant based. Recognition by private hospitals and private medical insurers (PMI) to treat patients in the independent sector is limited to those with an NHS Consultant appointment or, in a few cases of purely private specialists, the possession of the appropriate training record and qualifications. Such recognition is normally granted without any problem.
Since the inception of the NHS 60 years ago consultants have had the right to independent practice based on a “fee for service” arrangement with their patients. Thus, for those consultants who wish to treat patients privately, a contract exists between the consultant and the patient which is predominantly a professional one (duty of care) but also a financial one whereby the patient is responsible for the consultant’s (reasonable) fees.
Private patients may be self funded or supported by outside agencies (such as employers or foreign embassies) who may guarantee fee payment. In the majority of cases the patients will have Private Medical Insurance (PMI) but this does not absolve them from direct responsibility for their fees for which they, the patient, may seek reimbursement from their PMI up to the limit of their allowance. This arrangement must stand even if the consultant submits his/her account directly to the insurance company. The insurer does not pay the consultant’s fee although in the majority of cases there is a direct payment made to the consultant. In fact the insurer is reimbursing the patient for the consultant’s fees. If there are shortfalls due to some restrictions of benefits in the PMI then this becomes the responsibility of the patient. To reinforce the principle of the contract with the patient some consultants insist on billing the patient directly.
Implicit in these arrangements is the fact that consultants should, whenever possible, give the patient an estimate of potential charges for their treatment. This clearly cannot apply in emergency situations or if unforeseen clinical circumstances arise which require extra care or specialist attention. In all cases it is to be expected that the consultant charges are fair and reasonable.
FIPO strongly believes this system of care and fee charging has worked well, as it allows choice of consultant for the patient (who is generally guided by the GP’s advice or the consultant’s reputation rather than the fee structure) and it allows the consultant independence of practice.
These principles of practice have been laid down in the FIPO Charter which has the support of major Royal Colleges, Specialist Associations, the GMC and the Patients Association:
AXA PPP New Schedule of Fees and Terms and Conditions for Consultants
The new Terms and Conditions and Fee Schedule proposed by AXA PPP have just been announced in July 2008. For several months prior to this, newly appointed consultants were not allowed to apply to PPP for recognition to treat PPP subscribers. This embargo has now been lifted but all new consultants (and some established consultants) will be obliged to adhere to PPP’s new Terms and Conditions which now includes a Schedule of Fees. This is the first time that PPP has published a Fee Schedule but the level of these fees are not the prime consideration, as the issue is about the principle and the details within the new Terms and Conditions which PPP are attempting to unilaterally impose.
This PPP initiative should not be confused with the old BUPA Consultant Partnership which was something that many objected to but which was at least a voluntary agreement by consultants to maintain their fess at BUPA rates in return for a small bonus on operative fees at the end of the year. The new PPP schedule is quite different as it is a compulsory agreement with the sanction of non recognition by PPP if a consultant does not comply.
Our initial enquiries with PPP suggested that this new Schedule was applicable only to newly appointed consultants applying for recognition for the first time. This in itself is not acceptable to FIPO, but in fact it is now understood that established consultants will also be affected.
In essence the new Terms and Conditions mean
- All newly appointed consultants applying for PPP recognition must adhere to these fees and cannot charge the patient shortfalls. Failure to comply could result in de-recognition by PPP.
- If a PPP subscriber is treated by a non-recognised PPP consultant then none of the other providers (hospitals or consultants) will be reimbursed by PPP for that episode (which is a new stringent term).
- Although PPP say this is not directed at established consultants they have actually included intensive care specialists and oncologists who are required to stick to these reimbursement rates.
- Consultants who have been delisted for some reason by PPP may regain recognition but under PPP’s current Terms and Conditions (presumably meaning these new ones)
- It is possible, though uncertain, that consultants who have had their fees disputed by PPP will be also be put onto this schedule. PPP has a flagging system for certain consultants who they allege are charging more than their definition of “usual and customary” and many consultants have been “capped” by PPP or have been asked to negotiate their fees directly with the company. This new Schedule would give PPP the simple option of imposing a Fee Schedule on those consultants.
There are many aspects to this “agreement” and consultants forced into this by whatever route will have lost their complete independence. The direct contract with the patient will be completely undermined and there may well be a reduction of patient choice. If this PPP strategy is successfully and progressively implemented to the wider consultant body there is no doubt that other insurers would follow suit.
The trainee organisations are most concerned about the implications for their members as they come up to consultancy and whilst they may have other more immediate and pressing concerns about their careers this has been seen as a direct threat to their future independence.
Newly appointed consultants are generally not well informed about private practice issues and should seek advice before engaging with PPP. Established consultants in intensive care and oncology and others in different specialties who are threatened should also assess these carefully and seek advice before they decide if they wish to treat PPP subscribers under these conditions.
This issue is also explored in the latest Newsletter from FIPO...