Guidance for Consultants

The WPA Schedule has been produced for the use of specialists and their staff, using the OPCS - Office of Population Censuses and Surveys codes and CCSD codes, the narrative description for each procedure code of which has been agreed.

The current maximum benefits that WPA will reimburse to our policyholders (for OPCS/CCSD designated procedures) are based on detailed country-wide analysis from our sophisticated systems coupled with continuing dialogue with the Profession.

The benefits almost always meet the fees charged to our policyholders. There are occasions when fees invoiced to our policyholders may differ from the customary and reasonable levels. In these instances a letter of explanation to the Medical Services Department, or to WPA´s Medical Advisor, will enable us to determine the appropriateness of settling such invoices.

Our Schedule has been produced for the use of specialists and their staff, using the OPCS - Office of Population Censuses and Surveys codes and CCSD codes.

All practitioners must abide by the Good Medical Practice guidelines of the GMC and surgeons abide by the Good Surgical Practice guidelines from the Royal College of Surgeons.

WPA would welcome comments, criticisms and further help to ensure that our Schedule continues to be regarded as reasonable and relevant.

Established treatment

WPA considers as established treatment to be:

Treatment which falls into one or more of the following categories:

  • it is an established clinical practice in several centres in the UK
  • it is supported by publications in the UK peer review journals
  • it involves the use of drugs that are recognised and licensed in the UK for safe use for the condition being treated
  • it is approved by the Interventional Procedures Committee of the National Institute of Health and Clinical Excellence (NICE) or the Medical Devices Agency
  • it is considered to be acceptable clinical practice by WPA's Medical Advisors in the particular circumstances.

We will also consider benefit to cover treatment that falls outside these categories and which can be regarded as experimental provided that the patient to whom such treatment is offered becomes part of a trial registered by a recognised non-commercial registration agency, such as UKCCCR. It is recommended that if a patient is to be offered non-established treatment, WPA should be contacted so that prior authorisation can be given before any costs to the patient are incurred. Benefit will be provided for new procedures or treatment regimes within the maximum of the nearest most appropriate established procedure benefit level.

Shortfalls

Whilst most specialists' fees will be settled in full because they come within the maximum benefit levels set out in the WPA Schedule, it must be remembered that the contract for financial settlement exists between the patient and the practitioner and the insurance company simply offers benefit to the customer (your patient) to help with the settlement of such fees.

If it is anticipated that a shortfall will occur, this should be explained to the patient before the treatment is undertaken to avoid misunderstandings later. Our experience is that it is not commonly understood by patients that the contract is between the patient and the specialist, rather than between the specialist and the insurer.

In order to avoid embarrassment to our policyholders, WPA reserves the right to withdraw specialist recognition if the fees charged are repeatedly in excess of the procedure benefit described in the Schedule and are considered to be unreasonable and there appears to be no justification for them.

Cover

As a specialist, you are asked to ascertain whether your patient (our customer) has any exclusion on their policy. If doubt exists, it is advisable for patients to check with WPA before treatment is started.

The range of cover depends on the policy held by our policyholder and differences exist between one insurer and another, in particular with regard to conditions associated with pregnancy and psychiatric illness.

WPA health insurance policies cover secondary care of acute illnesses and injuries following referral to the specialist by the General Practitioner; they do not cover primary care. (The Guernsey Islander range has specific terms - please refer to scheme literature for further details.)

It is WPA´s policy to define an acute illness or injury as a disease, illness or injury that is likely to respond quickly to treatment which aims to return the patient to the state of health they were in immediately before suffering from it, or which leads to their full recovery. Like other medical insurers we do not cover chronic illness. By this we mean a disease, illness or injury which has at least one of the following characteristics:

  • it continues indefinitely and has no known cure
  • it comes back or is likely to come back
  • it is permanent
  • it means you need to be rehabilitated or specially trained to cope with it
  • it needs long-term monitoring, consultations, check-ups, examinations or tests

In most cases it is expected that a management plan would be provided by the Specialist to the General Practitioner. WPA do not provide benefit for Specialists undertaking on-going care, simply because it is the patient's preference.

It is WPA's policy to request that the patient's General Practitioner completes the claim form as s/he is in the best position to inform us of the duration of any symptoms leading to referral and any relevant previous history. Physiotherapy will generally only be covered within the limits imposed by the patient's policy following the acute episode for which the physiotherapy was requested by the Specialist or General Practitioner.

Multiple procedures

For multiple procedures, additional benefit is payable for the second and subsequent procedures carried out under the same anaesthetic. This additional benefit is calculated as a percentage of the maximum benefit payable for the procedure itself; the extra amount is not based on the maximum benefit for the first procedure. The percentages are therefore as follows:


1st procedure 100% of the benefit for that procedure.
2nd procedure 50% of the benefit for this 2nd, defined procedure.
3rd and subsequent procedures 25% or the benefit for the 3rd or subsequent, defined procedure.

If the operator also provides local anaesthesia or sedation and code AC100 is not appropriate we will consider paying up to 50% of the anaesthetic fee for that procedure.

Unbundling

WPA will not, however, pay separately for the component parts of a single procedure, as the maximum fee takes into account all the generally accepted elements of the procedure. Furthermore, such procedure fees cover the pre and post procedure care. The anaesthetic benefit, as defined in the Schedule, is only payable against the fees of an attending anaesthetist, and covers routine pre and post procedural attendance and care.

Other Services

Where a specialist provides additional services to patients such as pathology tests or prostheses over and above a normal consultation or procedure, then the cost of such items may be passed on to WPA at cost with a handling charge of no more than 10%. Such arrangements should be pre-authorised with WPA as in many cases the cost of such items is allowed for within the hospital charging tariff already agreed for the procedure/investigations.

In the event that a specialist wishes to bill for medical facilities such as MRI or theatre fees and consumables, WPA should be contacted in advance and a "Clinic Agreement" agreed in order for such services to be eligible for reimbursement.

Specialist Recognition

WPA is reviewing the criteria which apply to Specialist status. All Specialists must be medically qualified. All Specialists seeking recognition must have their names on the GMC Specialist Register. All consultants appointed by a properly constituted Consultant Advisory Appointment Committee to a consultant post within the NHS will be regarded as specialists: Those who have held such a post in the past may be granted recognition, but this will be at WPA's discretion.

Those currently given discretionary recognition will continue to be recognised by WPA without necessarily having their name on the Specialist Register.

Specialists currently practising outside the NHS and seeking recognition should apply individually for specialist recognition and will be asked whether their names are on the Specialist Register and if not, what steps have been taken to enter the Specialist Register. They will also be asked to provide evidence of continuing medical education, details of any audit process in which they are engaged and the form of peer group review to which they are exposed. Additionally, references may be requested from Specialist colleagues recognised by WPA, and the Medical Advisory Committees of the hospitals providing Practice Privileges.

WPA recognises the importance of freedom of choice, freedom for the patients to see the consultant of their choice, for consultants to look after their patients in the hospitals of their choice in order to ensure that the best resources and staff are available to optimise patient care.

Practice Privileges

WPA is also concerned to learn of the criteria used by private hospitals when offering admitting rights or Practice Privileges. In particular, we seek assurances that those Specialists offered Practice Privileges only practise techniques for which they have received appropriate training.