Health Insurance Claims

In your membership agreement we explain that we will not pay charges higher than those customarily made. This rarely happens but it is obviously important that we should only pay fees that are at the level normally charged. Through experience we have established what is generally charged for all the procedures that we cover and we query any charges which are above that normal range. Our decision reflects both domestic and international practice where appropriate and cost of living indices.

All patients should be given a quotation of the charges for treatment before they are committed to incurring costs. If a specialist has reason to believe that his charges may not be met in full by us, this must be made explicit to the customer at the outset. A request by a surgeon to settle his fees directly may be an indication that his fees are higher than what we would consider to be fair and reasonable.

The component parts of single procedures or services must not be itemised out and billed as if they were separate or additional services. As a guide, there is no clinical intervention which should routinely need more than one code. Atlas Healthcare will not reimburse additional charges for component parts of single Procedures.

Where two procedures are performed at the same time Atlas healthcare will pay the full benefit for the highest rated procedure and an additional 25% when two procedures are carried out and 40 % for three or more procedures. The additional percentage however should not exceed 50 % of the listed benefit for the second procedure. Such as undergoing a J1880 - Laparoscopic Cholecystectomy (tal-gebla) and a T2400 - Umbilical Hernia (tal-ftuq). If done separately the surgeon's fee payable for the J1880 would be €1,500 and that for the T2400 €300. When both procedures are carried out at the same time Atlas Healthcare would pay an additional 25% of the most complicated procedure (J1880) which comes to €375 but since this amount is greater than 50% (€150) of second procedure, then in this case Atlas Healthcare would pay the full €1,500 plus €150 for the second procedure.

Our business is conducted on the basis of good faith. We monitor claims using data mining and routinely audit claims by reference to medical records. We operate a policy of zero tolerance of fraud and misrepresentation. We consider the following to constitute fraudulent billing:

• Exaggeration of the complexity of the procedure performed - for example coding a diagnostic procedure as if it were therapeutic.
• Misrepresentation of the medical history or the procedure performed.
• Omission of material facts.
• The use of jargon or technical information which whilst strictly correct is presented in a way likely to mislead a non-medically qualified claims assessor (an example would be a claim for laser in situ keratomileusis (LASIK) coded as a keratoplasty).
• Unbundling.