BUPA query

melbury

Does anyone know if BUPA would cover a second operation for the same condition?

I know that they do not cover chronic conditions, but if the first operation hasn't resolved the problem and another different type of op is required, do you think they would agree to cover this?

dizzie

You really would have to take this up with BUPA. Have you seen the surgeon and has he/she recommended a second op? If so, they should be able to give you a procedure code for it which you can then speak to BUPA about to see if they'll cover it.

If on the other hand, you haven't returned to see the surgeon and are simply thinking that a second op might work, then in the first instance, you need to get authorisation for a further consultation to seek the surgeon's opinion. Then, once you have some firm recommendations you can seek approval for further funding from BUPA.

Be warned however, BUPA have cut its reimbursement levels massively this year (even though they've had pretty much a 20 year freeze in payouts for surgical procedures for the last 20 years....so inflation alone means doctors have been getting less and less from BUPA in real terms). Recent cuts (frequently of 45-50% this year) have meant that patients are either going to be left with shortfalls or BUPA may recommend that you see a cheaper (possibly newly qualified) consultant if you want a procedure paying for in full.

Sorry, this is probably not what you want to hear (particularly if you have a complex problem and have already had unsuccessful surgery), but BUPA are not being transparent about what they have been doing this year - they are expecting providers to tell patients that BUPA won't pay them as much...which is not what patients want to hear when they are in a position of needing treatment! The situation is so serious that the BMA is even recommending that doctors invoice patients directly.

One recommendation I can make is this. If BUPA are prepared to pay for a second op, check out if your surgeon can do this for the (frankly pretty naff) rates that BUPA are prepared to pay. If not, and you need the operation costs to be covered fully, BUPA may recommend a doctor to do this.

If BUPA do recommend someone - bear in mind that it is a telephone advisor who is doing this (i.e. someone who has no clinical knowledge!). I would advise that you try to find out more about any doctor that BUPA recommends. Some information may be found on the hospital's website and you can also look on the GMC website. Failing that, you could speak to your GP to get advice as to whether the doctor suggested is appropriate. The reason I say this is simple: Consultants in any specialty (e.g. orthopaedics) often have areas of "specialist interest". For example - if you have a hip problem and need to see an orthopaedic surgeon - you want to see one who specialises in hips... not someone who dabbles in a bit of everything, or someone who spends 95% of their time as a shoulder surgeon!

If you are unhappy with BUPA, remember that your consultant can sometimes write a letter of support, explaining why you need a further op...and why it is not satisfactory to class your condition as "chronic". At one time, the term "chronic" used to mean a condition that couldn't be cured....it simply had to be managed by treating symptoms. Nowadays, some insurers are trying to class some conditions as chronic based purely on the length of time you have had them (e.g. six months or more).

And finally, if you are unhappy then you should complain to your insurer and to the insurance ombudsman. BUPA have not brought down their customer's premiums...indeed they go up a fair bit every year, but (having been a BUPA policyholder myself), I can tell you that you are getting nowhere the same value for money that you used to with this company and they are officially now one of the worst payers in the industry.

Hope that this reply will make you a little more savvy when dealing with BUPA and will save you from any unpleasant surprises (i.e. forewarned is forearmed), but wishing you all the best and hoping you manage to get this sorted out.

melbury

Thank you dizzie for your detailed reply.

The surgeon hasn't said that another operation is needed, but if the forthcoming CT scan shows that the problem has come back over the past month, then undoubtedly he will just have to go for a laparotomy to try and resolve it.

The surgeon we requested is recognized by BUPA but does not operate within BUPA limits, so undoubtedly we will already be in debt to him. I have no idea what their limits are or what surgeons charge - suppose it depends entirely on the operation.

I don't understand how they can cut their reimbursement levels, surely they have to pay the hospital in full for scans, operating theatre time and accommodation etc. My OH has already have about five CT scans this year and is about to have another one:eek:

Must say that I have always found BUPA to be extremely good and have not yet encountered any problems with them paying for treatment.

Do BUPA actually make much money? Seems that the hospitals charge them a fortune for use of their facilities.

prowla

I think in general that medical insurance won't cover pre-existing conditions (ie. diagnosed before taking up their insurance).

However, I wouldn't trust BUPA as far as I could throw them.

They once billed me for treatment that was already paid for, and kept harassing me about it, and then got in a debt collector, despite the fact that my specialist there told them it was paid.

Based upon my experience, and in my opinion they are not to be trusted.

dizzie

Hi again Melbury,

There are two components to any invoice sent to BUPA:

The first is the hospital invoice. It includes costs for use of facilities, consumables used and any investigations. The hospital portion of the bill is usually the largest amount.

The second is the invoice for the doctor. Since doctors are usually self employed, this invoice is usually sent separately by the doctor's secretary. This invoice covers the doctor's time and expertise for carrying out consultations (which usually come out of your limited outpatient allowance), and also any procedures (i.e. carrying out the surgery).

It is the latter reimbursement levels (i.e. those paid to the doctor for carrying out a procedure) that BUPA have been cutting this year, so if you go ahead with any surgery be sure to find out what the surgeon is going to charge (i.e. ask the surgeon's secretary for procedure code and cost) and then (if BUPA do agree to pay), give them the procedure code and find out what they are prepared to pay. This will ensure that you are aware of what the shortfall will be and guard against any nasty surprises afterwards.

We too had been insured with BUPA for >10 years, and previously also found them very good...but very recent dramatic changes in rules and reimbursement amounts brought in by BUPA have made a big difference and some people are now having to fund around 50% of the doctor's invoice for the surgical procedure themselves.

melbury

dizzie wrote: »

Hi again Melbury,

There are two components to any invoice sent to BUPA:

The first is the hospital invoice. It includes costs for use of facilities, consumables used and any investigations. The hospital portion of the bill is usually the largest amount.

The second is the invoice for the doctor. Since doctors are usually self employed, this invoice is usually sent separately by the doctor's secretary. This invoice covers the doctor's time and expertise for carrying out consultations (which usually come out of your limited outpatient allowance), and also any procedures (i.e. carrying out the surgery).

It is the latter reimbursement levels (i.e. those paid to the doctor for carrying out a procedure) that BUPA have been cutting this year, so if you go ahead with any surgery be sure to find out what the surgeon is going to charge (i.e. ask the surgeon's secretary for procedure code and cost) and then (if BUPA do agree to pay), give them the procedure code and find out what they are prepared to pay. This will ensure that you are aware of what the shortfall will be and guard against any nasty surprises afterwards.

We too had been insured with BUPA for >10 years, and previously also found them very good...but very recent dramatic changes in rules and reimbursement amounts brought in by BUPA have made a big difference and some people are now having to fund around 50% of the doctor's invoice for the surgical procedure themselves.

Thanks again dizzie,

Too late to ask the surgeon's secretary because OH has already had one operation. I don't know what surgeon's charge but hopefully any extra won't be too much more than the amount BUPA pay him.

As previously mentioned, he definitely does not come within their agreed limits and so I am expecting to pay something on top.

OH has to have another CT scan, that won't please them as they get charged a fortune for each of them:( - wonder if there is a limit per year???

Do BUPA make a profit? It seems that very often if a consultant knows you are going through private medical insurance, they really hike the price up - bit like vets with pet insurance. I know someone who paid £150 for a procedure that was exactly the same as my OH had done a few years ago and BUPA got charged nearly £500 - that is just wrong.

dizzie

melbury wrote: »

Thanks again dizzie,

Do BUPA make a profit? It seems that very often if a consultant knows you are going through private medical insurance, they really hike the price up - bit like vets with pet insurance. I know someone who paid £150 for a procedure that was exactly the same as my OH had done a few years ago and BUPA got charged nearly £500 - that is just wrong.

I think again, you are more likely to be talking about the hospital fees rather than the consultant's fees. Remember, the procedure fees that are paid to the consultant really haven't gone up in the last 20 years or so, so doctor's are unlikely to discount rates further for self funders.

However, hospitals sometimes offer a "self pay" rate which is lower for self funders. It is the hospital fee portion which is lower. Not always the case mind you. BUPA sometimes negotiate a really low rate for some items. At our local Spire Hospital, BUPA have negotiated a rate of £350 for an MRI scan, whereas self funders pay around £200 more!!