CS healthcare Westhill Consulting Guide to Consultants

Guide to Consultants

This page is designed to provide Consultant/Specialists with guidance on how we apply the terms of the 'your choice' policy in relation to treatment and fees.

Fee Reimbursement
Surgeons Fees - this is the level of reimbursement for the principal practitioner performing the procedure, which could be a Consultant surgeon, physician, radiologist or anaesthetist. The listed fee will cover all pre and post operative assessments directly associated with a day case or in-patient stay and is also to cover those common variances and complications related to the original surgery or procedure such as:

Bleeding (with the exception of returning to theatre where a further appropriate code may be charged).
Provision of IV fluids and management of medications.
Infection & management of deep vein thrombosis.
Management of catheters and drains.
Removal of sutures and simple wound care.

Anaesthetist Fees – the level of reimbursement for the anaesthetist is to cover a general or regional anaesthetic (including epidurals), the listed fee is to include:

A simple pre-operative assessment.
The induction and maintenance of the anaesthesia, and related life support.
Pain relief post operatively and until discharge.
Intravenous / Central Line Management independent of:
High dependency / Intensive Care / Critical Care up to 24hrs post-operatively.

Epidural for analgesia set up in the period preceding surgery or 24 hours after the surgery will be settled in full according to the listed level of reimbursement.

Local anaesthesia, with or without IV sedation performed by the principal practitioner is covered by code AC100 and will be reimbursed in full in addition to the appropriate procedure code.

Please note: Where a patient requires a separate consultation prior to the admission for surgery, because they have co-morbidities which may need investigating, or discussion as to the type of anaesthesia and aftercare or whether they are suitable for a procedure. Subject to CS Healthcare being notified of the need, this will be covered.

Multiple Procedure Policy
For a single procedure we will pay the 100% customary and reasonable fee according to the required CCSD code and its recognised complexity.

Primary procedure - up to 100% of the listed fee price.
2nd procedure - up to 50% in addition to the primary procedure.
3rd procedure - up to 25% in addition to the primary and second procedure.
For bilateral procedures not identified within a specific CCSD code we will pay 100% of the actual procedure plus an additional 66%.

Critical Care
CS Healthcare policies automatically cover up to 3 days Critical Care following an elected pre-authorised procedure, the first 24 hours being covered within the listed procedure fee, and the further two days can be billed separately. Beyond this period the Managed Care Team at CS Healthcare must be contacted for further advice. They can be contacted on 020 8410 0440.

Other information
'Standby' Fees: These are billed for surgeons and anaesthetist who may need to intervene in an event of an emergency, where appropriate, these fees will be reimbursed according to the correct CCSD code.

Second Consultant: If out of medical necessity there is the need for a second consultant to assist during a procedure, please contact the Managed Care Team for assistance, and consideration for reimbursement can be given. Fees for a surgical assistant are not covered. If a second Consultant is to be present during a theatre time to perform a separate procedure under the same anaesthetic then they will be reimbursed accordingly using the allocated CCSD code.

Where there is no CCSD code appropriate to the procedures / surgery that is required: We are aware that on occasions there might not be a CCSD code appropriate to the procedure or surgery which needs to be performed – in these instances please provide the details to the Managed Care Team, who can be contacted on 020 8410 0440. Where you have a procedure which is likely to be performed on a regular basis and there is not a code you should inform the hospital that you are performing the procedure in, or member of the CCSD group at CCSD Project Office, c/o Westhill Consulting, Amadeus House, Floral Street, London, WC2E 9DP - or via their web site at www.ccsd.org.uk or by email at
ccsd@tribalgroup.com.

Experimental Treatment & Clinical Trials
CS Healthcare policies do not cover experimental treatment, unlicensed drugs or Clinical Trials. We do however cover cases where we would have covered an established procedure, up to a similar financial limit, providing a clear treatment plan is submitted to CS Healthcare, and we have the consent of the patient that they fully understand the nature of their treatment. Please contact the Managed Care Team for further advice on 020 8410 0440.

Payment
CS Healthcare will settle invoices directly to each provider within 28 days of receipt of the invoice by cheque; however, if you prefer BACS transfer we are happy to pay by this method.

To receive payment from CS Healthcare you will need to be recognised by us and added to our provider system. Therefore if you have not already received payments from CS Healthcare, you will have to provide us with a CV outlining your career, including your GMC number, your Consultants post and hospitals to which you have admitting rights; and as outlined above your preferred method of payment, and your billing address.

Co-payments & Excesses
Some CS Healthcare policy holders will have opted for a co-payment or excess arrangement in return for paying cheaper premiums, in a situation such as this any sum which we are not able to pay will be detailed on the payment advice sheet sent by us. The patient will also be sent information on how much to settle with you.

Shortfalls
CS Healthcare makes every effort to avoid our members having a shortfall on the levels of fee reimbursement, Where a fee cannot be paid in full because there is not a reason related to a medical necessity or major complications not normally covered by the surgeons or anaesthetist fees, you will need to liaise with your patient directly for the outstanding sum. We will have informed the policy holder of any shortfall that is their liability.

All CS Healthcare members must contact us prior to any, consultations investigations or treatment to enable us to confirm if benefit is available. They will then receive a Pre-Authorisation Certificate out-lining the terms of their insurance for each procedure they undergo. This certificate clearly states what level of fees we would expect to reimburse for each procedure.