BUPA

I work for a private practice in London and it is my job to liaise with insurance companies to determine whether our patients are covered for various procedures, consultations and operations. I also deal with the undesirable phenomenon known as "shortfalling" which I will explain later. Having spoken to BUPA and other insurance companies on a daily basis for the last six months, I would like to share my knowledge and experience of BUPA.

GETTING THROUGH
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I am not a policyholder of BUPA's and only call the claims helpline. This is LO-CALL number: 0845-7553333 based in Manchester. Generally you get straight through to a human voice after 20 seconds once a camp Mancunian voice has welcomed you to the "BUPA services helpline". I did a little of this over the week 14th - 18th June 2004 and went straight through to a human 72% of the time (62 out of 86 calls). For a call centre, I think that's pretty impressive.

SHORTFALLS
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In insurance terms, any hospitals, surgeries, consultants or operating rooms are referred to as "providers". In any other business they would be creditors or suppliers. BUPA and other insurance companies are viewed by the public as a financial, peace-of-mind body between the patient and provider.

A shortfall occurs when a provider's set charge for a particular procedure is "X" amount of pounds and the maximum the insurers are willing to pay is less than that. The difference is the shortfall and 95% of the time in my experience, the patient has had to foot this balance. Here are some tips to avoid shortfalls.

1. When seeking cover for a particular procedure always get an exact quote from the provider and, if applicable, something called called an OPCS code. This is usually a letter followed by four digits. Inform your insurers of the quote and code and ask how much they will pay towards it. I work in the treatment of breast cancer and shortfalls happpen about 50% of the time, so please check.

2. BUPA rarely send out claim forms for treatment in my particular field and instead use "authorisation codes". PLEASE note that generally their codes are valid for one visit (usually an initial consultation) unless otherwise stated. Any further visits or treatment you require from the provider may well need a separate code. I have known BUPA to refuse to pay us because a patient didn't get a code before her visit. The patient was, therefore, liable to settle her account personally, even though she was insured. Bite the bullet and DO AS THEY SAY.

3. Check your policy carefully and note any excesses. I know it goes without saying but BUPA will deduct the value of your excess from the first invoice they receive. If your excess is £100 and they receive, for example, a £125 consultation fee from a Harley Street clinic they will only settle £25 of that. It's stating the obvious, I know, but please be aware.

4. Beware of "unbundling". This is when two or more procedures are carried out at the same time and billed separately on the provider's invoice. BUPA will not pay for each OPCS code, only the major procedure and then 25% for the second and 10% of the third. This can also lead to a significant shortfall. When you quote you OPCS codes to them, check they won't "unbundle" your claim. It's a little-known hazard to the public and one that more people should be made aware of.

SECURITY
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BUPA staff at the Manchester call centre are VERY helpful. Your policy number (two digits followed by a slash and another nine numbers) is generally all you require to enable you to talk about your account. They do a sensible security check and ask for your postcode and date of birth. For data protection, they will NEVER disclose your address to a third party: I have had to chase patients for shortfalls, found they've moved house and gone to BUPA who refused to help me. Annoying for me but reassuring for the policyholder, I'm sure. Apart from the treatment performed on the policyholder, no financial and detailed information about the actual policy is ever disclosed to a provider. Given the vast range of BUPA policies this must be reassuring in the sense that no one can tell how tight or flush you are!

GENERAL
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BUPA keep their policyholders informed of any shortfalls BEFORE the payment is sent to the provider. A policyholder statement is sent showing the invoice details, date balance, "ineligible amount" (shortfall/excess) and amount paid to provider. The amount due to the provider from the policyholder is also listed on this sheet. At this point it is advisable to speak to the provider to confirm the shortfall and make arrangements for paying before the chase letter come.

OVERVIEW
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Generally, I find BUPA a great company to deal with as a provider. They're courteous, informative and some of the "robots" in the call centre are actually rather human and knowledgable. Even knowing what I know about their policies and the advent of shortfalls, if I had to choose a health insurer, I would plump for BUPA.