Introduction

Billing Principles: Introduction


These Billing Principles will give you clarity in your work with us and support for your patients’ care.

In these Principles we tell you what services and treatment we will and will not pay for. The information will guide you on when you need to contact us, helps in paying your invoices quickly, and ensures our work together runs smoothly.

Following these Principles also means giving us the information we need, at the right time. This helps ensure we can best support your patient’s care and that commercial discussions don’t get in the way of treatment.

We do expect you to adhere to these Principles, which support your recognition and form part of your contract. Failure to adhere to these principles may affect your recognition with us.

Important Points


  • We will pay eligible fees in full when you charge up to the level shown within the Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/ for treatment you have provided. We will not pay for you to supervise services provided by others.
  • Please do not bill for any service or treatment that is not listed in the Schedule of Procedures and Fees, outlined in these Billing Principles or outlined in your contract, without first seeking approval from AXA PPP healthcare.
  • In line with the good practice guidelines of your regulatory authority, any medical records or information you send us should be complete, accurate, clear and signed by the treating provider. They should include details of procedures, treatments or consultations as appropriate and include the patient’s name, relevant dates and treatment start and end times. If in any doubt, please send us typed copies of medical records, with copies of the originals.
  • As the treating provider, we hold you responsible for ensuring the information you provide, such as coding or medical notes, is accurate. This is important as we use this information to assess eligibility and to settle claims.
  • We need time to consider pre-operative requests which may affect your fees or the way you carry out a procedure. Please send us the relevant information at least five working days before the scheduled treatment.
  • We expect you to follow the ethical guidance provided by your regulatory body. An example of such guidance from the General Medical Council (GMC) can be found here: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor
  • Please do not consider the provisions of any sections of these Billing Principles in isolation. Each section should be considered in relation to the others.

    1: Pre-treatment and pre-authorisation provisions


    1.1 Consultations
    We define a consultation as a meeting between patient and provider to:
  • evaluate the nature and progress of an active condition
  • establish a diagnosis, prognosis and treatment plan.

    Consultations should be face-to-face, unless you have an agreement with us for remote or telephone consultations. We allow Mental Health Practitioners to perform remote consultations if this is within their scope of practice.

    We set the consultation fee, which includes room and other charges, regardless of time taken or complexity. We expect you to see each patient for the appropriate time to treat their individual condition. We do not expect to be invoiced for additional time or double sessions when treatment has overrun the scheduled time.

    We expect to be billed for only one consultation for each patient on any given day.

    You may perform certain minor operations during consultations. Please bill for these using the codes listed in our Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/

    We will pay for in-patient consultations if you:
  • are the physician in charge of the patient’s care,
  • have visited them in hospital and
  • are not providing routine post-operative care.

    We would not expect you to bill for a consultation if you:
  • are on call, or
  • have operated on or provided anaesthesia to the patient in question within the past 10 days, or
  • are performing planned surgery for that patient on the day of the consultation.

    Please see Section 2.3 of these Principles for guidance on submitting an exception to this principle.

    1.2 Tests, pathology and diagnostic radiology
    You should only request diagnostic tests or pathology tests when you have reasonable suspicion of a medical condition, in line with national guidelines and evidence-based practice and where the tests are required to direct and manage a patient’s treatment plan.

    For example, we would expect to see patients managed for sepsis according to the NICE sepsis quality standards https://www.nice.org.uk/guidance/qs161/chapter/Quality-statement-2-Senior-review-and-antibiotic-treatment

    We would therefore expect, for example, to see a hospital charge for a lactate blood test, but not for a D-dimer blood test (unless this was also indicated by other relevant clinical symptoms).

    We will not generally pay you separately for diagnostic tests, pathology or diagnostic radiology at facilities in our network, or for reporting on the results of these diagnostics. We pay the hospital, clinic or facility directly for these services. If required, you should negotiate appropriate payment for your services with the facility.

    You may bill for therapeutic interventional radiology following our Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/ For diagnostic tests you perform in your private consulting rooms you should submit invoices using CCSD coding and narratives published on the CCSD website https://www.ccsd.org.uk/

    We will accept invoices for specimens taken in your private consulting rooms from any recognised pathology facility which has an agreement with us.

    1.3 Information you should provide before a consultation
    We expect you to comply with the Private Healthcare Market Investigation Order 2014, published by the Competition and Markets Authority (CMA).

    Before confirming an outpatient consultation appointment, you should give your patient the following information:
  • the estimated cost of the consultation
  • details of any financial interests you may have in the facility or its equipment
  • a list of all insurers who recognise you
  • a statement that insured patients should check with their insurers the cover they have
  • a reason for further tests or treatment
  • an estimate of the cumulative cost of the treatment pathway which has been recommended. This should include: - all fees you charge separately from hospital fees - contact details for any other consultants whose fees are not included in the quote - a statement of services which have not been included in the estimate, such as those resulting from unforeseeable complications. Where alternative treatments are available but the appropriate treatment can only be decided during surgery, the estimate should set out the relevant options and associated fees.

    Please also provide this information to the Private Healthcare Information Network (PHIN) www.phin.org.uk which provides patients with information to help them make their private healthcare choices.

    Treatment at a facility outside our network
    The majority of our members have chosen a policy requiring them to receive treatment at one of our network facilities.

    We pay all charges for eligible treatment at any hospital listed as a network facility in line with our agreements. In normal circumstances, we pay only a small daily benefit for treatment at a facility that is outside of our network and is not listed in our directory.

    In exceptional circumstances, if a patient needs facilities or treatments which are not available at one of our network facilities, we may pay the charges.

    You must agree this specific exemption with us before treatment or, in an emergency, as soon as possible after admission. Where we have agreed, we will pay all charges for eligible treatment at the relevant facility which is best placed to provide the necessary care.

    To request an exemption, please complete the Hospital Exemption Request form on our Provider website https://www.axappphealthcare.co.uk/network-exemption The Network Development team will review your clinical reasons and let you know if we will accept treatment outside our network.

    2: Treatment Provisions


    2.1 Coding
    We work with the Clinical Coding and Schedule Development (CCSD) group to help create industry standard procedure codes. We publish any codes we introduce in the ‘Important information’ section of our Schedule of Procedures and Fees. Please use these codes when billing us for treatment. They should be reasonable and within their intended purpose, as defined by the CCSD: https://www.ccsd.org.uk/

    Procedure narratives and codes are protected by copyright and may not be altered or used in any way other than as published in the Schedule of Procedures and Fees.

    If you believe there is no appropriate code for the treatment you wish to carry out or that the narrative does not reflect what you are doing, please contact the CCSD directly and request a new code. We review requests and possible changes with them regularly.

    2.2 Our fees
    We list the majority of procedures we pay for in our Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/

    We will pay eligible fees in full when you charge up to the level shown within the Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/ for treatment you have provided. We will not pay for you to supervise services provided by others.

    Our fees include all component parts, for example:
  • pre-operative assessment
  • the procedure itself, including local anaesthetic and/or intravenous (IV) sedation by the main operator
  • all routine aftercare, including any consultations within 10 days of the procedure.

    Please see Section 2.3 of these Principles for guidance on submitting an exception to this principle.

    We pay the hospital, facility or clinic directly for the in-patient services listed below. We do not pay you separately for these services:
  • consumables, including drug costs
  • equipment charges
  • in-patient therapies.

    If required, you should negotiate appropriate payment for your services with the facility.

    2.3 Our fees: exceptions
    Please do not bill for any service or treatment not listed in the Schedule of Procedures and Fees, outlined in these Billing Principles or outlined in your contract, without first seeking approval from AXA PPP healthcare. If you believe an additional fee is appropriate, for example where you have to see a patient within 10 days of their surgical procedure because the wound has reopened, please:
  • tell us what fees you would like us to reconsider and why
  • submit a copy of your clinic letter using our specialist fees enquiry form https://provider.axappphealthcare.co.uk/individual/individual-provider-support/ We will then consider your request.

    2.4 Unsure what code to use for surgery?
    We may still cover procedures which are not listed by code in our Schedule of Procedures and Fees. We’ll need additional information from you to help us consider your proposed treatment.

    If you can’t find the code you need, please:
  • give us a detailed analysis of what you’re planning
  • include the nearest appropriate code from our Schedule of Procedures and Fees and/or the CCSD website and
  • submit a copy of your clinic letter using our specialist fees enquiry form https://provider.axappphealthcare.co.uk/individual/individual-provider-support/
  • make sure we have this information at least five working days before the procedure is due to take place.

    We’ll use this information to help find the correct code and we’ll tell you the corresponding fee.

    When there is no appropriate procedure code, we will allocate the nearest code and may also review the fee independently, considering any additional complexities.

    Once you have the right code, please share this with your patient so they can authorise their treatment. This will also help avoid any doubt when you invoice us.

    2.5 Unbundling
    We take a common-sense approach to unbundling and will list the most frequently occurring procedures together. The list is not exhaustive, but we do not expect procedures to be broken down into their component steps.

    Here are some examples of unbundling which show what we would consider unreasonable combinations or billing:
  • 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, for example suturing to close an operation wound
  • charging for in-patient care or intensive treatment unit (ITU) care routinely considered part of the procedure, for example with a complex procedure such as a Whipples procedure
  • charging for pre-operative or post-operative assessment or analgesia, including local anaesthetic or IV sedation by the specialist performing the procedure
  • using procedure combinations whose primary purpose is to increase reimbursement. An example of this would be charging for wound infiltration with local anaesthesia or a Whipples procedure with a gallbladder removal code, as these elements are integral to the operation
  • charging for an anaesthetic when an anaesthetist has provided anaesthetic services
  • charging for a multidisciplinary team meeting
  • consultations during a course of chemotherapy.

    In most cases, we will outline which procedures we don’t expect to see billed together on our Schedule of Procedures and Fees and publish these on our ‘Important changes’ document on our website.

    Sole Procedures
    A code has ‘sole procedure’ in the narrative when it is usually performed by itself. Otherwise it is part and parcel of another procedure in the same area of the body. You should normally bill sole procedures in isolation, but there may be times that it is appropriate to bill a sole procedure code alongside another code. Please tell us about these exceptions by following the guidance below.

    Exceptions
    Our unbundling or sole procedure rules may not apply if you perform procedures on a separate area of the body in a single session. If this applies in a specific case please:
  • complete the specialist fees enquiry form on our Provider website https://provider.axappphealthcare.co.uk/individual/individual-provider-support/ , selecting ‘query about our billing principles’, at least five working days before the procedure
  • supply the relevant codes and areas of the body to support your request.

    We’ll tell you whether you can bill separately for these codes. If you submit an invoice without contacting us we will not pay all the separate charges or we may recoup money paid by mistake.

    3: Bespoke Requests


    3.1 Fee Uplifts and Multiple Specialist Requests
    On occasion you may need to submit more than one code for surgery. When this happens we will pay the full amount for the procedure with the highest complexity and 50% of the fee for the second procedure.

    We appreciate that we can’t address every medical situation or surgical complication in setting fees. If you are planning a complex series of procedures which are not covered in the principle outlined in the paragraph above, we may consider a bespoke request.

    This may include pre-operative or post-operative uplift requests and multiple specialist requests.

    We define these here:

    Pre-operative uplift request
    Where you anticipate a procedure will be more complex than expected, for a specific clinical reason, we will estimate the fee. We will need:
  • an explanation of why an enhanced fee is appropriate
  • the estimated time in theatre
  • an indication of what you are likely to charge
  • a full description of the procedure being performed and
  • associated procedure codes.

    Please note we will periodically audit the pre-operative requests we receive, and may request operation notes and anaesthetic charts post-operatively.

    Post-operative uplift request
    We understand that complications can arise during surgery and we will consider paying an enhanced fee if this occurs. Please send us any information you think will help us decide whether an increased fee is appropriate. As a minimum we will need:
  • a copy of the original operation notes (please also submit typed notes if handwritten notes are unclear)
  • anaesthetic charts
  • an indication of the fee requested.

    Multiple specialist requests
    We will consider requests for two or more surgeons during a patient’s operation, either because:
  • more than one specialism is clinically necessary (a gynaecological surgeon and a colorectal surgeon, for example), or
  • clinical guidance from a UK professional body (or another medical entity we recognise) indicates that two or more specialists from the same specialism need to be present during the surgery.

    You must agree these requests before going ahead with the procedure. Please send us the following information to support this request:
  • details of each specialist
  • an explanation of why each specialist needs to be in surgery
  • the anticipated procedure length and an indication of time in theatre for each specialist
  • an explanation of what each specialist will do
  • an indication of fees for each specialist and any supporting clinical guidance.

    When agreeing treatment we will provide an estimate of fees paid for each specialist. If, after treatment, you would like us to adjust our estimate, please send us your operation notes and anaesthetic charts, so we can understand:
  • your role in the procedure
  • the time spent in theatre and
  • the complexities faced.

    We will then confirm the fee we will pay you for the treatment.

    Please submit your bespoke request using the specialist fees enquiry form on our Provider website https://provider.axappphealthcare.co.uk/individual/individual-provider-support/ We review all requests individually using the evidence you provide.

    We want to make sure your patients can confidently book treatment without worrying about what we will pay. To support with this, please allow at least five working days’ notice for any pre-operative requests, including coding queries and requests for multiple specialists. We need this time to review the information you send us and make a decision.

    Otherwise, we’ll review your request post-operatively, at your own risk. Please note we do not pay for surgical assistants or for you to supervise services provided by others.

    Ethical guidance for bespoke requests
    We expect you to follow the ethical guidance provided by your regulatory body. An example of such guidance from the GMC can be found here: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor

    This guidance states, in paragraph 78, domain 4, under the section ‘Honesty in financial dealings’, that: “You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients.”

    We do not expect you to redirect a patient’s care or cancel treatment if you are unable to agree your preferred fee with us. We will take situations like this seriously and we may withdraw your recognition in these circumstances.

    3.2 Unproven treatment
    We do not provide benefit for experimental or unproven treatments. These are treatments which do not meet our definition of conventional treatment, as defined below. These treatments include those using new technology or drugs, where safety and effectiveness have not been established or generally accepted. We may make a contribution to unproven treatment if there is a suitable, equivalent conventional treatment.

    Please contact our Medical Support team (MedicalSupportTeam.HEALTH@axa-ppp.co.uk) before undertaking treatment which might be considered unproven. Please send us:
  • your details
  • the appropriate CCSD code
  • a description of what you will be doing during surgery
  • date of surgery
  • the hospital where the treatment will take place
  • who will be present during surgery, including the anaesthetist’s name and provider number
  • the patients name, date of birth and membership details.

    You should not use codes covering existing procedures for new and as yet uncoded procedures.

    Conventional treatment
    We define conventional treatment as treatment that:
  • is established as best medical practice, is practised widely within the UK and
  • is clinically appropriate in terms of necessity, type, frequency, extent, duration and the facility or location where the treatment is provided; and has either
  • been shown to be safe and effective for the treatment of the medical condition through substantive peer reviewed clinical evidence in published authoritative medical journals or
  • been approved by the National Institute for Health and Care Excellence (NICE) as a treatment which may be used in routine practice.

    If the treatment is a drug, the drug must be:
  • licensed for use by the European Medicines Agency or
  • the Medicines and Healthcare products Regulatory Agency and
  • used according to that licence.

    4: Specific provisions


    4.1 Anaesthesia provisions
    Anaesthesia reimbursement includes:
  • pre-operative assessment, on the ward or at a clinic
  • the anaesthetic itself, including all intra-operative and post-operative care and any care in an ITU or high dependency unit (HDU) expected during the procedure
  • inserting and removing all lines and catheters, including central venous pressure (CVP), arterial (ART), continuous cardiac output (CCO), hemofiltration vascaths, nasogastric and urinary tubes
  • monitoring and
  • analgesia, including nerve blockage, neuroaxial blockade or patient controlled analgesia.

    You should not list any of these items as additional charges.

    Following the Guidelines for the Provision of Intensive Care Services jointly published by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) (Edition 1.1 2016), we will pay a daily fee as listed in our Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/ to the intensivist caring for a patient in an ITU. This pays for all ITU care including, but not limited to:
  • insertion and care of CVP/ART/vascath/pulmonary artery catheters
  • dialysis/haemofiltration
  • chest drains and
  • tracheostomy insertion or endotracheal tube changes.

    We will not pay this fee to the anaesthetist present during the surgery.

    4.2 Injections and infusions
    As they are not separate surgical procedures, we do not accept separate charges for:
  • subcutaneous, intramuscular or intravenous injections, including vaccinations where eligible
  • drug/electrolyte infusions, including blood/fresh frozen plasma/platelets.

    We include injections and infusions within our standard consultation or hospital fee, whether given during a planned consultation or by appropriate nursing staff during a hospital stay.

    4.3 Chemotherapy and Radiotherapy
    Charges for the prescribing and supervision of chemotherapy should be made in accordance with the schedule set out in Chapter 18 of our Schedule of Procedures and Fees https://provider.axappphealthcare.co.uk/schedule-of-procedures-and-fees/

    Consultation
    A fee for consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment.

    Chemotherapy
    The coding covers all care relating to the clinical supervision and planning of the delivery of chemotherapy (only ONE of the following: X0001 OR X0002 OR X0003 OR X0004) regimens and the engagement and management of patients, including but not limited to:
  • regime prescription
  • supervision of planning and treatment delivery
  • expected side effects management and the prescription of an alternative regimen
  • supervision of all outpatient, day patient, and inpatient care.

    Only one supervision fee will be paid for any course of treatment regardless of whether a single or multiple drug combination is used. We expect that invoices for chemotherapy and biological supervision should be made at the end of the cycle of treatment.

    Radiotherapy
    Charges for the prescribing and supervision of radiotherapy should be made in accordance with the schedule set out in Chapter 20.

    As per CCSD guidance, it is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0012) are to be used by consultants only for delivery. Please see the CCSD Schedule for more information: https://www.ccsd.org.uk/ccsdschedule/CCSDScheduleCode?Chapter=20&Section=0&subsection=0&ctype=0&numitems=100&page=0

    A fee for consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment. These codes cover all care relating to the clinical supervision and planning of the delivery of radiotherapy regimens and the engagement and management of patients, including but not limited to:
  • regime prescription
  • supervision of planning and treatment delivery
  • expected side effects management and the prescription of an alternative regimen
  • supervision of all outpatient, day patient, and inpatient care, including any transfusion of blood/blood products.

    We expect that invoices for radiotherapy supervision and treatment delivery should be made at the end of the cycle of treatment.

    5: Administration and governance


    5.1 Submitting invoices
    You must submit all invoices to us for eligible claims within six months of treatment. Please do not send patients invoices or seek payment from them directly.

    To help us to pay you promptly, please submit invoices electronically via our e-billing provider Healthcode www.healthcode.co.uk/medical-billing/home . When you open this link you should select the option to ‘register for HC VEDA’.

    5.2 Payment
    We send you remittance advice telling you the total amount we are paying you for treatment, which patient the payment relates to and any reasons the invoice wasn’t paid in full (for example, if there was a membership limitation).

    Your patients receive similar statements advising them of any costs their membership doesn’t cover, which they must settle with you.

    To ensure patients can pay you quickly, please let us share your bank details with your patients by filling out this consent form on our Provider website https://provider.axappphealthcare.co.uk/specialist-opt-in-form/. This lets us share your bank details when needed.

    We will also send your patients the invoice address you gave us when you became recognised. Please ensure it is an address you are happy for your patients to know (a business, rather than a home address, for example). If you would like us to use a different address, please update your details on the Private Practice Register PPR: https://www.theppr.org.uk/

    Requests for medical documentation
    During your patient’s treatment we may request medical information or documentation to make a decision about a claim. We will let you know where to send this information when we request it.

    As the treating provider, we hold you responsible for ensuring the information you provide, such as coding or medical notes, is accurate. This is important as we use this information to agree treatment for patients and settle their claims quickly.

    We expect you to comply with the good practice guidance of your regulatory authority when submitting this information.

    For example, the general medical record keeping standards of the Royal College of Physicians expect “every entry in the medical record should be dated, timed (24 hour clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed”. https://www.rcplondon.ac.uk/projects/outputs/generic-medical-record-keeping-standards

    We expect your documents to be complete, accurate, clear and signed by you. They should include details of procedures, treatments or consultations as appropriate and include the patient’s name, relevant dates and treatment start and end times.

    If you submit documents or information that do not adhere to these standards, we will not be able to review them and we cannot consider your request. If in doubt, please supply typed notes with the original copies.

    Please note:
  • we will ask for this information to be submitted as soon as possible, but no later than 28 days after we have asked for it
  • it is your responsibility to gain your patient’s consent to share this information
  • without this consent, we may not be able to review the information you have sent us
  • we try to request the minimum appropriate information needed to make a decision
  • under the General Data Protection Regulation (GDPR), you are the controller of this information and you are responsible for ensuring you send the correct information to us.

    We do not pay you for providing this information or for completing reports.

    We may audit medical notes as part of our quality control procedures. Once the member signs a consent form authorising this disclosure, we will ask you to provide us this information.

    5.4 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 GMC and to the police as appropriate. We consider the following examples constitute fraudulent billing:
  • exaggerating the complexity of the procedure. For example, coding a diagnostic procedure as if it were therapeutic
  • misrepresenting the medical history or the procedure performed
  • omitting material facts
  • using jargon or technical information which, while strictly correct, is presented in a way likely to mislead a non-medically qualified claims assessor: a claim for laser in situ keratomileusis (LASIK), for example, coded as keratoplasty
  • unbundling (see section 2.5 on Unbundling, above).

    We may share your details under Article 2 of the GDPR for the purposes of the prevention, investigation, detection or prosecution of criminal offences or the execution of criminal penalties, including the safeguarding against and the prevention of threats to public security.
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