Many doctors and surgeons maintain a rewarding and busy private practice providing treatment to patients funded by a private health insurer, such as BUPA, AXA, Aviva or Vitality. This is often an attractive choice for both practitioners and patients, allowing tailored treatment to be delivered outside of the many constraints of the NHS.

As with all types of insurance, private medical insurers will normally only cover the costs of such care if specified strict criteria have been properly met. Where those requirements are complied with, there is a risk that either the practitioner or the patient will not be properly paid or reimbursed for the treatment provided. One area where disputes with the insurer can commonly arise is billing of the practitioner’s fees. If an insurer considers that the practitioner’s bill fails to comply with its stated requirements, it can refuse to pay the practitioner. Where an insurer perceives that a practitioner is repeatedly submitting bills which are not compliant, this can trigger an audit for the purposes of scrutinising the individual’s billing practices. This can lead to rejection of further bills – or even a demand for reimbursement of previous payments.

Potential implications of a billing dispute between a doctor and an insurer?

Where there are concerns that a practitioner is not adhering to billing rules, such as not using the correct billing code for the correct procedure, the insurer may undertake an internal investigation. If the insurer concludes that appropriate billing practices are consistently not being followed, the insurer might not be willing to engage the practitioner’s services in the future. If a billing dispute with an insurer leads to the practitioner being ‘derecognised’ by the insurer, this prevents the practitioner from seeing patients covered by that insurer. This could lead to an immediate and significant loss of earnings for the practitioner.

Depending on a number of factors, if a practitioner is ‘derecognised’ by a particular insurer, this could in turn lead to private hospitals or clinics suspending the practitioner’s practising privileges.

An insurer may also conclude that the billing practices go beyond mere inaccuracy and amount to fraud or dishonesty. Such a conclusion is likely to trigger a General Medical Council (‘GMC’) referral that could become an investigation into the practitioner’s fitness to practise. During a GMC investigation, it is possible that the practitioner’s GMC registration can be suspended or restricted whilst the allegations are fully investigated. The Medical Practitioners Tribunal has recently heard a GMC case which stemmed from an audit investigation undertaken by a private health insurer. In that case, the alleged use of incorrect codes in the submission of the practitioner’s invoices led to allegations of dishonesty being raised against them.

Therefore, the potential implications of a billing dispute between a GMC-regulated practitioner and a private health insurer could become very serious. Aside from the obvious impact on a practitioner’s financial situation if the range of patients they can see is suddenly limited, such investigations often also present a risk of reputational damage which can linger long after the process has concluded. This is often accompanied by a significant amount of stress for the practitioner which can result in a negative impact upon emotional wellbeing.

What can you do to avoid a billing dispute?

As in most medical scenarios, prevention is better than cure. The first step is to be aware of the kind of scenarios that can lead to billing disputes, and make sure that you understand the rules and requirements for all the private health insurers that you have a ‘recognition’ with. Some of the more common causes of disputes include:

• Using incorrect billing codes when submitting invoices
• Charging above insurer approved fee rates
• Unbundling (billing separately for procedures that should be billed together)
• Providing incomplete or inaccurate medical history
• Omitting material facts
• Providing unclear information about the complexity of procedures
• Keeping poor or inaccurate supporting records

Insurer requirements are often detailed and complex – and they are revised from time to time. It can be very easy to inadvertently fall foul of the criteria when submitting invoices. The risk of mistakes can be minimised by ensuring that you implement accurate billing practices, and review them regularly to keep them up to date with the insurers’ requirements. The best ways to avoid a billing dispute with private medical insurers are to:

• Ensure that you understand the insurer’s requirements and billing principles, and periodically review these
• Check bills carefully for accuracy prior to submission
• Check with the insurer if you are unsure about the correct code to use when submitting the claim – most insurers have a ‘code checking’ service for practitioners, so do use it
• Ensure that you seek pre-approval for treatment from the insurer where required
• Where pre-approval is required, instigate discussions with the insurer at the earliest opportunity
• Maintain transparency with patients and insurers about fees
• Keep full and accurate records of all treatment provided and discussions with insurer
• Keep full and accurate records of any agreements with insurers about the fees you can charge for specific tests of treatments. Even if the insurer changes its ‘standard’ fee for a particular test or treatment, you may still be entitled to charge a higher fee if you had specifically agreed that in writing with them – but the burden will be on you to prove that to them if they question the charge.

How should you deal with billing dispute if one arises?

If you do find yourself involved in a billing dispute, it is best to take it seriously from the outset and take pro-active steps to prevent the situation from escalating. The first practical step to take is to ensure that you understand the substance of the dispute. For example if the insurer is concerned you have used the wrong billing code, take time to consider whether this could be a miscommunication about the precise nature of the procedure, treatment or test. You will always need to review your records to remind yourself of what treatment was provided and how you submitted your bill. It may also be necessary for you to review the insurer’s billing requirements – you may find that you had been unaware of changes to codes or requirements. Early, open and careful communication is often key to resolving such matters quickly. If you can see that a mistake has been made, the best course of action is to communicate this to the insurers and work with them to try to resolve and rectify the issue. If, having reviewed the matter, it is still unclear to you why the bill is being rejected, politely ask for further clarification from the insurer.

On the other hand, if you remain of the view that your bill was appropriate and should be paid by the insurer once you have reviewed all of the relevant information, you should explain to the insurer why you consider your costs are justified. In doing so, you should collate and provide to the insurer all of the evidence that supports your position. If an agreement with the insurer cannot be reached right away, you should consider seeking independent legal advice on how to best resolve the matter.

Whatever the scenario, be mindful of the tone and content of your communications with the insurer. Whilst such matters can become frustrating for a practitioner, you should strive to appear reasonable at all times. Remember that there is a significant imbalance between the commercial power held by the insurer compared to yours. The terms and conditions that many insurers have with their registered practitioners enables the insurer to de-register the practitioner at the insurer’s discretion. Even if you think the insurer is entirely in the wrong, any perceived discourtesy from you is unlikely to help you reach a favourable resolution! Any responses that you do provide to the insurer should be carefully checked for accuracy to avoid any suggestion of dishonesty being made further down the line. You should also keep a careful record of the correspondence and discussions that take place. Taking this approach will also assist you in the event that matters escalate in the direction of a GMC referral or suspension of practising privileges.

How can Incision help?

Involvement in billing disputes with private insurers can be challenging, but Incision is here to support you. Incision provides a 24/7 medico-legal helpline to assist you when such issues do arise. As your medical indemnity provider, we can advise you on how to minimise the risk of any potential referral to the GMC or suspension of practising privileges, and when you should consider seeking independent legal advice in relation to any dispute. Our sympathetic and knowledgeable medico-legal advisors are ready to provide you with expert assistance in dealing with these difficult situations.