Your insurer fee schedule hasn't moved in years, and the gap is compounding

Private medical insurers set fee schedules that individual consultants rarely challenge. Rates vary significantly between consultants performing identical procedures, and insurers rely on this opacity to suppress costs. Consultants who have not renegotiated in three or more years are typically 15% to 30% below the rates available to those who actively negotiate. The negotiation process is specific to each insurer and requires knowledge of their internal rate review processes, the right contact points, and the benchmarking data to support a credible ask.

• Private medical insurers often set fee schedules that are not transparent and are rarely proactively reviewed or adjusted for inflation.
• This opacity allows for significant variation in rates paid to consultants for identical procedures, with insurers leveraging this to suppress costs.
• Consultants often lack the time, resources, and specific knowledge of insurer processes and market data required for effective negotiation, leading to a passive acceptance of stagnant rates.

Consultants who do not actively negotiate their fees with Private Medical Insurers may be leaving significant revenue on the table due to stagnant fee schedules and varying rates. (Independent Doctors Federation, 2024)

• Increased administrative time spent on fee queries and appeals
• Difficulty in attracting and retaining consultants due to uncompetitive rates
• Reduced income for consultants due to below-market rates
• Increased administrative burden and costs for practices managing complex fee schedules
• Potential for reduced consultant morale and engagement
• Risk of consultants limiting treatment options based on insurer reimbursement
• Damage to consultant's professional reputation if perceived as offering lower quality due to fee restrictions
• Negative patient perception if choice of consultant or treatment is limited by insurer

What it looks like in practice

• Consultants receiving lower reimbursement for procedures compared to peers
• Patients facing unexpected shortfalls due to insurer's restricted fee schedules
• Increased frustration among consultants regarding administrative complexities with PMIs
• Difficulty in planning practice finances due to unpredictable fee uplifts