Introduction

Introduction


This is the Schedule of procedures and fees for providers recognised by AXA PPP healthcare. It includes codes for procedures for which our policies provide benefit and is based on work undertaken by the Clinical Coding and Schedule Development group (CCSD). It also details billing principles which apply to invoices for private medical services provided to our members.

Reimbursement status


In all instances specialists or clinical and complementary practitioners must work within their scope of practice and in line with their professional codes of conduct. Any new procedures that are not routinely undertaken within their routine practice must be considered and agreed by AXA PPP healthcare in advance and in conjunction with the clinical governance committees at the treating facility.
This document sets out what AXA PPP healthcare would expect specialist and practitioners to charge for the services they provide to patients. We will pay eligible fees in full when a specialist or practitioner charges up to the level shown within this document for treatment that they have provided; no payments will be made for supervision of services provided by others. All services claimed for must be listed in the Schedule of Procedures and Fees.
We have identified certain specialists and practitioners whose fees exceed this limit and these specialists’ and practitioners’ charges will always be limited to the level shown in the Schedule of Procedures and Fees for Fee Limited Specialists and any excess charge over this amount will not be reimbursed.

Billing principles


The main principles which all providers must adhere to as a condition of recognition are as follows:

Procedure fees
The operator fee for a procedure includes all component parts of that procedure including preoperative assessment, the procedure itself and all routine aftercare including out-patient consultation for at least the first ten days.

Injections
We do not accept separate charges for giving sub-cutaneous, intramuscular or intravenous injections (or vaccinations where eligible) as on their own these are not deemed to be separate surgical procedures and any charge for giving injections is covered by the standard consultation charge.

Coding Invoices must be coded using the industry standard CCSD codes as listed in this Schedule. The only item which should appear on an invoice is the (usually single) CCSD code for the procedure being performed. This code should only be used for the use set out in the standard description. If a code states ‘as sole procedure’ in its narrative it should not be performed in addition to another procedure. If any procedure is undertaken which is not coded, specialists should contact the specialist fees team at specialistfees@axa-ppp.co.uk

Unbundling
The component parts of single procedures or services must not be itemised out and billed as if they were separate or additional services. As a guide, there is no clinical intervention which should routinely need more than one code.
We will not reimburse additional charges for component parts of single procedures and will withdraw recognition from providers who persistently unbundle charges. Unbundling includes:
  • Charging for two procedures where one is part and parcel of the other or is so frequently performed that it is in effect part and parcel.
  • Charging for in-patient care or ITU care where this is simply routine post-operative care.
  • Charging for pre-operative assessment or post-operative analgesia including nerve blocks.
  • Using procedure combinations whose primary purpose is to increase reimbursement. An example of this would be charging for wound infiltration with local anaesthesia.
  • Charging for anaesthetic when anaesthetic services have also been provided by an anaesthetist.


Multiple procedures
Different insurance companies have different rules about fees for multiple procedures. Where two procedures are performed at the same time we will pay full benefit for the highest rated procedure and 50% of the fee for the second highest rated procedure. Only in the most exceptional circumstances and on a case-by-case basis discussed prior to any treatment taking place will third procedures be considered for additional reimbursement. Please contact the specialist fees team for advice at specialistfees@axa-ppp.co.uk

Multiple specialists
Where two or more specialists operate on a member as a matter of preference, only a single fee is claimable.

Where two specialists perform different procedures and where the second procedure cannot be performed by a single specialist, then the two specialists will be treated separately for the purposes of this fee schedule. An example would be a mastectomy followed by a DIEP flap.
These requests must be preauthorised and will be considered on a case by case basis. Please contact the specialist fees team for advice at specialistfees@axa-ppp.co.uk.
In any other circumstances where two specialists are required, this should be agreed in advance with the specialist fees team.

Consultation charges
A consultation means a face-to-face consultation only. Only a single consultation may be claimed on any one day. We do not provide benefit for consultations using electronic communication for example by email, telephone or across the internet. Consultation fees are inclusive of any room charges or any other additional charges.

In-patient care charges are claimable only by the physician in charge of the case and are for face to face visits and are not claimable for being on-call. Other specialists may claim benefit for specific consultations for specific problems only, but this should be pre-authorised. We consider out-patient follow-up within ten days of a surgical procedure to be an integral part of post-operative care and thus to be covered by the charge for the procedure and this would not be reimbursed as an extra service.

During the course of a members treatment we may need to request medical information or a Medical Information Form may need to be completed to obtain relevant information about a claim. We try to ensure that only the minimum amount of information is requested in order to service the request. Any medical information or Medical Information Form submitted must be completed and/or signed by the controlling specialist. Please note that we do not expect any charge to be made for the provision of this information or the completion of the report.

Anaesthetic fees
The benefit for anaesthesia includes an amount for pre-operative assessment (whether on the ward or at a clinic), the anaesthetic itself including any lines or monitoring and post-operative care including analgesia, care in ITU or HDU, nerve blockage, neuroaxial blockade or epidural. None of these should be listed as extra. Operations should be coded using the single CCSD code which describes the operation performed plus all its component parts. Additional codes should only be used for genuine separate and additional procedures. There is no code for CVP lines as part of anaesthesia or ITU care and specifically the code L9110 should not be used.

Anaesthesia by the operator
There are many procedures which are commonly performed under local/topical anaesthesia by the operator such as investigations and simple procedures, including but not limited to those procedures listed in Chapter 1. E.g. removal of skin lesions. In these instances the published surgical benefit includes an amount for anaesthesia by the operator and no additional charges should be made for this service. For some procedures normally performed under general or regional anaesthesia an additional fee of up to £100 may be made for IV sedation by the main operator as long as no separate anaesthetic is billed. An example of this is a colonoscopy under IV sedation. This should be billed as code X3510 and an asterisk will show which codes this is allowed with. If you require any further advice please contact the Specialist Fees team by email specialistfees@axa-ppp.co.uk.


Intensive care
For patients in intensive care which is medically necessary and not for routine care post-surgery, a fee is payable as indicated in this Schedule. This covers consultation, monitoring and procedures such as CVP lines, arterial lines and dialysis, pulmonary artery catheters etc. Additional fees may be claimed for procedures with a CCSD code and can be claimed by the specialist in primary charge of the case. Other specialists may claim for necessary consultations for specific problems but not a daily fee.

Chemotherapy and radiotherapy
Charges for the administration and supervision of chemotherapy and radiotherapy should be made in accordance with the principles set out section 18 of this Schedule.

All inclusive fee arrangements
Our contracts with hospitals listed in our Network of Hospitals www.axappphealthcare.co.uk/specialists include some services where specialists’ fees are included within the prices we have agreed with the hospitals, notably diagnostic radiology, pathology and in-patient therapies. In these circumstances specialists should negotiate appropriate remuneration for their services with the hospital. This arrangement provides clarity and reassurance for patients that all charges associated with such services are covered under our contract with the hospital.

Radiology
All diagnostic radiology must be billed through the hospital in accordance with contracted rates. Therapeutic interventional radiology can be billed in accordance with fees contained in this Schedule.

Pathology
All pathology charges must be billed through the hospital or clinic where the procedure took place. Where the specimen is taken in a consulting room owned and managed by a consultant specialist, we will accept invoices from any recognised pathology facility with which we have a fee agreement.

Facility charges
Charges may be made for facilities provided there is a formal agreement in place between the facility and AXA PPP healthcare.

Submission of Claims


In line with our members’ policies, all eligible claims must be submitted within six months of treatment. Invoices for eligible treatment can be submitted electronically or by post but full treatment details must be provided to avoid processing delays. For more information on appropriate billing format please refer to our website at www.axappphealthcare.co.uk/healthcare-professionals/submission-of-claims

Payment


Payment will be made by monthly interval payment. This will be accompanied by a remittance advice which provides a breakdown of the total amount paid, the members it relates to and any shortfalls in payment made such as shortfalls due to a policy excess. A similar remittance advice is also sent to the member advising them of any liability including an invoice to show the amount of any shortfall and to whom this should be paid. To support this payment, the member will also be provided with the details of the specialist's invoice address that was either submitted on the application form or more recently on a change of address form. Specialists are advised to consider this if they have provided a home rather than a business address for this purpose.

Effective and appropriate medical treatment


We do not provide benefit for experimental or unproven procedures, including those using new technology or drugs, where safety and effectiveness have not been established or generally accepted. Please contact the Medical Department at AXA PPP healthcare before undertaking treatment which might fall into this category. Under no circumstances should codes intended for existing procedures be used for new and as yet uncoded procedures. The narratives and codes are protected by copyright and may not be altered or used in any other way except as published in the Schedule of procedures and fees.

Fraud and misrepresentation


The Fraud Act 2006 sets out the legal definition of fraud and creates offences of fraud by false misrepresentation, fraud by omission and fraud by abuse of position. A person who makes a false statement, omits material facts or misuses a position of trust with the intention of causing loss to a third party is guilty of fraud even if he or she does not personally gain and even if the deception fails. The law includes false statement made to any device capable of receiving information. Home Office guidance on the application of the Act states that it is intended to cover false statements made to insurance companies at underwriting.

Our business is conducted on the basis of good faith. We monitor claims using data mining software and routinely audit claims by reference to medical records. We will not tolerate fraud and misrepresentation and will cease doing business with any provider who provides false, misleading or selective information. We will also refer cases of fraud to the General Medical Council and to the police as appropriate. We consider the following examples constitute fraudulent billing:
  • Exaggeration of the complexity of the procedure performed for example coding a diagnostic procedure as if it were therapeutic.
  • Misrepresentation of the medical history or the procedure performed.
  • Omission of material facts.
  • The use of jargon or technical information which whilst strictly correct is presented in a way likely to mislead a non-medically qualified claims assessor (an example would be a claim for laser insitu keratomileusis (LASIK) coded as keratoplasty).
  • Unbundling.

Audit


On occasion, we conduct audits of medical notes as part of our quality control procedures. Specialists and practitioners who are recognised by us for benefit purposes are required to provide this information on receipt of a consent form signed by the member authorising this disclosure.

Network policies


The majority of our members (over 90%) have chosen to purchase a network policy which requires them to receive treatment at one of the facilities listed in our Directory of Hospitals. Under the terms of our network arrangement, we settle hospital charges in full for eligible treatment at any of these listed hospitals, but only a small daily benefit is paid if treatment is undertaken at a facility which is not in our Directory. This arrangement does not, however, compromise access to care that is medically necessary.
Should a patient need facilities or treatments, which are not available at a convenient hospital in our Directory of Hospitals, then we will cover the costs of eligible treatment in full at whichever hospital is best able to provide the necessary care. However, this must be agreed with us before treatment takes place or, in an emergency, as soon as is possible after admission.

To request an exemption, please complete a network exemption referral form which can be found at www.axappphealthcare.co.uk specialists/contact us/Network Exemption/PDF Hospital Exemption form and fax it to the number below. The Network team will review the clinical justification for an out-of-directory admission and confirm whether it will be eligible for full reimbursement.

Network exemption team:

Helpline: 01892 772218

Fax: 0117 972 6006

Failure to pre-authorise out-of-directory admissions may result in the member incurring a significant shortfall in benefit.

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