Many patients may have had the experience that they cannot get the necessary referral to the specialist they want with their private medical insurance. This has become an increasingly troublesome phenomenon over the past year. It is particularly frustrating as private health insurance companies seem to be interfering with the referral process in a way that does not happen on the NHS. The basis for this seems to be in changes to their fee structure. That is to say that different insurance companies have unilaterally decided to change the fees they cover in relation to surgical treatments. For example, I myself have not changed my fee structure for hip surgery for the past 5 years and previously insurance companies covered these for their patients. Increasingly, these companies are deciding they do not want to cover these fees and therefore this leaves the patient with the worry of a shortfall.
For the surgeon this becomes very difficult, as individual companies want to agree different contracts. I have never particularly wanted to align myself with any individual insurance company. The problems arise when patients wish to see a particular specialist and the insurance company directs the patient to see someone who may not be appropriate for their particular condition. On the NHS we very rarely have any issues with patients requesting a referral from their GP or via another Orthopaedic Surgeon and we see patients from all over the country. It seems inappropriate that this referral pathway is being distorted in the private sector.
My advice to patients is that if you have done your research or had a recommendation who to see, you should insist on seeing the right person. The individual you speak to on the phone from your insurance company will not necessarily know much about your condition and will most likely be working to a different agenda. The monetary shortfall issues, if there are any, are often rather small and hugely exaggerated by the insurance company. After all, the reason many individuals pay for health insurance is to see and be treated by the person of their choice at a time that is more convenient to them. Insurance companies should be facilitating this, not obstructing it.