In the last few months, some private health insurers are rejecting claims for surgery that have a Medicare Item Number. This is leaving patients to either pay the whole amount up-front for their hospital treatment and then fight for reimbursement at a later date, or potentially make the tough decision to forego surgery. It’s making patients uncertain over changes to private health insurance!
The Australian Society of Plastic Surgeons (ASPS) was first to raise these concerns with the relevant regulatory authorities, funds and government.
Since then ASPS has been in a series of meetings with concerned stakeholders to collaborate on a solution which will give patients clarity about their insurance cover.
“Patients need to know exactly what a fund’s health product is, and how it works to decide how best to manage their health and their finances,” says Dr Kane, President, Australian Society of Plastic Surgeons.
“Cosmetic services have never been entitled to a Medicare Item Number and private health funds do not rebate for cosmetic procedures. And we do not dispute that. The difference now is that some funds have taken it upon themselves to question the doctor’s decision that the surgery is medically necessary, not cosmetic.
“That’s a move to an American style managed care health system and we reject it,” Dr Kane said.
ASPS has asked the private funds to freeze their recent procedural changes while a better solution is negotiated with Medicare, doctors and the funds to ensure certainty and transparency for patients.
Medibank Private and Bupa are two of the insurers introducing measures which they say will to help to guard against claims that are made for surgery that is intended purely for aesthetic purposes.
In a statement provided to Plastic Surgery Hub, a Medibank Private spokesperson said they have recently strengthened their audit process.
“As part of this process we have written to hospitals to verify a small percentage of claims that had missing information,” the spokesperson said.
“As a result of this audit process, we believe that some hospitals may have written to doctors questioning certain procedures and that this may have included plastic surgery.
“Some hospital operators have also requested that we confirm the eligibility of upcoming plastic surgery for our members to ensure it is for medical reasons, but we require supporting documentation.
“To satisfy hospital requirements Medibank recently implemented an interim process, which requires verification from the patient’s doctors, so that our members can receive treatment.”
The Medibank spokesperson told Plastic Surgery Hub that they had no intention of ‘weakening’ or ‘interfering’ with the doctor-patient relationship and that they would continue fine-tuning their systems with the relevant stakeholders.
“We have been and will continue meeting with specialty groups, including Australian Society of Plastic Surgeons, and hospital groups to develop a suitable on-going process that works for doctors and for our members,” the spokesperson said.
Bupa has said it will introduce eligibility criteria to hospitals in September to ensure claims are genuine.
The new systems have been questioned by some surgeons who fear legitimate claims may not be approved and that insurers will be given more decision-making power than doctors and patients.
Fears have also been raised about unsuccessful claimants being driven towards unaccredited facilities and to cheap overseas surgeons.
However, the Medibank spokesperson told Plastic Surgery Hub that they had no intention of ‘weakening’ or ‘interfering’ with the doctor-patient relationship and that they would continue fine-tuning their systems with the relevant stakeholders.
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