How we set our fees
Developing good working relationships with providers is vital to our future success. Our core belief is that customers should be able to concentrate on their treatment and recovery, safe in the knowledge that PruHealth is dealing directly with the administrative elements of their claim. For this reason we are committed to offering our members full refund for eligible professional fees. This means we will never pass on a shortfall to our customers for your procedure fees.
To achieve this, PruHealth is committed to reimbursing consultants at a reasonable rate, demonstrating that we value the training and expertise that is needed to deliver a quality outcome for our customer - your patient.
In 2011 a benchmarking review was completed reviewing the experience across the whole of the PruHealth book of business. As you are probably aware, reasonable and customary billing has historically been derived from market rates. However, PruHealth took the opportunity to compare remuneration levels with benchmarked professional earnings, accounting for local remuneration structures, international comparisons and comparison to other professions with similar levels of training and litigation threats.
This analysis considered complexity and operating time of procedures, practice and professional costs, staffing, administration and professional liability costs. It also considers efficiency / utilisation levels as well as the potential business risks associated with private practice, such as return on investment in property and equipment.
All of the above has resulted in PruHealth identifying the average hourly remuneration that a consultant in full-time private practice, with average practice and professional costs and working at average efficiency levels should earn. In addition to this, factors such as technical expertise, sub-specialty tertiary referrals and high complexity case mix are considered and measured against the actual invoice and challenged accordingly.
PruHealth believes that this robust analysis is unique in the industry in terms of deriving consultant rates. Similarly, this may help in assisting Consultants evaluate their professional worth on economic/remuneration models, rather than simply rely on using 'industry standards'.
Of course the issue with using historic industry standards is that like for like is often not compared. This can be demonstrated in the fact that some insurers have significant co-payment levels (up to 25%) to their published consultant rates, which in the long-term increases the un-affordability of private medical insurance.
As an innovative health insurer PruHealth would welcome the opportunity to engage with you and your representative bodies to share this work. We all have a responsibility to ensure that consultant tariffs are transparent to the consumer and based on professional worth, additional experience, the practice of cost-effectiveness and quality of outcomes.
Further to the comprehensive review undertaken in 2011, Operator and Anaesthetic fees were increased across the board in February 2012. PruHealth has completed a further review in 2013 and applied a further inflationary increase to all fees.
PruHealth hopes that you have found the above information useful when raising fees for professional services you have provided to our customers.