Matters in Healthcare: Not every hospital service is covered

Question: I have to regularly see a specialist at the hospital. I have insurance, but for some reason this care is not being paid for and I’ve been sent the bills. I thought every service offered at the hospital was covered by insurance so why are my claims being turned down?

Answer: Under current regulations, not every service or procedure performed at the King Edward VII Memorial hospital has to be covered by insurance. To avoid surprise bills you may want to check with your health insurer about the coverage your policy provides, before you receive non-emergency services.

There are two major components to every health insurance policy in Bermuda — the Standard Hospital Benefit (SHB) and the supplemental coverage. The SHB, which is mandated by the Health Insurance Act 1970, must be included in every health insurance policy sold on the Island and, locally, covers most hospitalization services and some non-hospital services (radiology and home medical services). 

The SHB is regulated by law and must be paid in full by all insurers. The fees are set annually by the Bermuda Hospitals Board (Hospital Fees) Regulations, and BHeC’s schedules for Diagnostic Imaging Fees and Home Medical Services Fees. All of these can be found on our website: www.bhec.bm/for-professionals/fee-schedules/

However, not all services listed under the BHB Fee Regulations are SHB. There are over 400 procedures that are explicitly excluded from SHB. It is possible that the services you received are not SHB and that is why they were not covered.

The supplemental benefits of a health insurance policy vary between insurance plans, but will usually cover physician visits and other services in the community. If the service you receive at the hospital is not listed as an SHB benefit, then the supplemental coverage provided by your insurance policy may pay for all, or part of, the service. 

If you believe the treatment you received should have been covered by your insurance policy, check with your insurer. If you are still unsure, BHeC can assist.

Question: Who decides which procedures are included in the fee schedules and how should I interpret them?

Answer: The fee schedules are set by Government and reviewed annually. The Bermuda Health Council oversees services included in the Standard Hospital Benefit, but not the services offered by BHB.

A quick summary of the four regulated fee schedules are:

• Bermuda Hospitals Board (Hospital Fees) Regulations:  These are approved by the Ministry of Health and Environment, and are arranged with four schedules that set fees for inpatient and outpatient services at King Edward VII Memorial Hospital and Mid-Atlantic Wellness Institute. Schedules 1 to 4 list the services covered by SHB, but particular attention should be paid to Schedules 3B and 4B. These are procedures at the hospital that are not covered by SHB.

• Bermuda Hospitals Board (Medical and Dental Charges) Order: The Order sets the fees physicians and dentists may charge for treatment of patients in Bermuda Hospitals Board (BHB) facilities or related to a hospital stay. Under section 13A of the Bermuda Hospitals’ Board Act 1970, physicians and dentists cannot charge fees beyond those set by the Order for services performed at BHB. 

• Diagnostic Imaging Fee Schedule: Lists 166 diagnostic imaging procedures covered as SHB at approved facilities (private, non-BHB facilities) and the fees for each procedure. 

• Home Medical Services and Fees: Lists the home medical services and fees covered under SHB and the agencies approved to provide the services. 

Should you wish additional information about these services, our website provides the details at: www.bhec.bm/for-professionals/fee-schedules/

And if you feel that you have been incorrectly billed, please contact your insurer first to ensure the reimbursement level is correct. Failing that, we at the Bermuda Health Council can assist. 

Answers supplied by Jennifer Attride-Stirling, CEO of the Bermuda Health Council.