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Best practice for healthcare providers

Believers in best practice

To protect members’ interests and the reputation of our brand, we choose to work only with providers who show a total commitment to these values:

High Standards for patients

All our providers must follow the requirements relevant to their practice, including:

  • Practice and evidence-based guidelines of relevant organisations, including specialty organisations and/or professional bodies
  • Practice and ethical guidelines of your professional body, e.g., for medically qualified consultants, the GMC
  • The National Minimum Standards for Private and Voluntary Healthcare
  • Clinical protocols and guidelines from specialist organisations
  • Reasonable standards of whole-practice audit.

You must hold a similar scope of practice in the private sector to the work you undertake in the public sector and to have adequate training and experience to deliver care independently at consultant level. You will ensure that you have had adequate training and exposure for the care you provide. If you are undertaking procedures, you will ensure you undertake an adequate volume of procedures, including at least ten supervised procedures prior to undertaking them unsupervised.

Making working together easier – for patients and for us

Our members expect us to be open and transparent with them at all times. So while we understand it can sometimes be difficult to discuss rates with patients, any provider who works with us has a responsibility to ask members - before any treatment starts - to check whether they have enough cover for their procedure.

Our providers must also be able to provide full details on their billing procedures and charges, which we’ll audit from time to time in order to protect members’ financial interests. For example, when a member thinks they’ve been overcharged and this causes them distress or financial embarrassment, this will trigger a review of the provider’s recognition status.

It’s always our aim to pay providers’ fees quickly and in full. To facilitate this process, invoices should be submitted via Healthcode electronic billing for practitioners  – a highly secure method which ensures accuracy and greater speed of payment.

No compromises on ethical standards

As all responsible providers, we are unashamedly committed to preserving the integrity of the private healthcare sector. So we continuously monitor claims trends and variant billing for signs of irregular billing patterns.
We value the fact that our providers in the huge majority interact with us with honesty, integrity, and transparency. On occasion we may spot a provider consistently charging in unusual or unexplained ways, we'll contact you where we feel this is happening. 

We consider all of the following to represent fraud

  • Up-coding - billing a procedure of higher complexity than the one performed
  • Unbundling - additional billing for component parts of a complex procedure
  • Billing for services that were not provided
  • Billing for services that were not medically necessary
  • Altering dates, description of services or medical records to secure payment
  • Misrepresentation of diagnoses or procedures to maximise payment
To avoid any doubt, read our unbundling rules on our Fee Structure page.

We fully support and are active in the development of CCSD coding principles to define unacceptable code combinations. These can be found on the CCSD website.

We're an active member of the Health Insurer Counter Fraud Group. We share information with other insurers for the detection and prevention of fraud subject to the provisions of the Data Protection Act.

If you become one of our recognised providers, you must comply with our best practice billing guidelines on Consultants Fees as further clarified by the CCSD coding principles, unless otherwise agreed.

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