Outpatient fees and Private Medical Insurer Preauthorisation:
A significant number of complaints come from patients who have exceeded their private medical insurer outpatient limit and then complain because they believe prices are not transparent.
Where they know what will happen in an outpatient appointment they can preauthorise the visit with their insurer in advance. However, when it is an investigative appointment and they do not know in advance what tests or procedures are required they are unable to do that.
Exceeding their outpatient fee limit may happen when they see a clinician in outpatients and are sent for a series of diagnostic tests which may take place at the same visit for speed and a joined-up consultation. It is very easy for outpatient allowances to be used up in one investigative episode (it obviously varies according to the policy held).
Business practice means it is not possible to have a list of OPD prices for each insurer as costs may differ between insurers, and insurers prefer to pre-authorise any diagnostic tests or procedures.
TIP:
• Ensure that when they sign and return the registration form before having their consultation (either at home or when they attend outpatients) their attention is drawn to the paragraph explaining their obligations to pay any shortfall from their insurer.
• Have a list of all diagnostic and outpatient procedures by specialty that the consultant can tick to give to the patient to show what is being requested or recommended.
• Give this to the patient when leaving the consultation and on the bottom of the list advise them to get preauthorisation from their insurer before having the tests done to ensure there is no shortfall in payment that they will have to make up themselves.
Offer them a private room they can use to call their insurer before going for the tests.