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:
The highest clinical standards
All our providers must follow the requirements relevant to their practice, including:
- Good practice guidelines of your specialty organisation or Royal College
- Good practice guidelines of your registering body, e.g. GMC, GDC, HPC
- National Minimum Standards for Private and Voluntary Healthcare
The highest financial standards
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, we recommend the use of Healthcode electronic billing for practitioners or hospitals/facilities – a highly secure method which ensures accuracy and greater speed of payment.
The highest 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. If we spot a provider consistently charging over and above our reasonable and customary rates without good reason, we’ll open a fraud investigation which we’ll pass onto to regulating organisations and / or the police.
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.
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 Consultant's Fees as further clarified by the CCSD coding principles, unless otherwise agreed.
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