Matters in Healthcare: How claims regulations affect you

Question: What are the Claims Regulations 2012?

Answer: The Claims Regulations 2012, is the short name for the Health Insurance (Health Service Providers and Insurers) (Claims) Regulations 2012. 

You can see why we shorten the reference to the legislation. 

This legislation abolished upfront charges and mandated health insurance claims include specific information.

Question: As a non-medical person, why do the Regulations matter to me?

Answer: These Regulations were enacted in 2012 so the insured portion of a health bill is not charged directly to you at the time of the visit. They also set-out mechanisms for health providers to be paid promptly by insurers.

Question: As a health professional, what does this legislation mean for my practice?

Answer: One of the most important requirements for health professionals is providing the necessary information to insurers for your claims to be processed swiftly. 

While insurers are required by the Regulations to pay promptly, they cannot do this without the information required under Schedule 1 of the legislation. 

Schedule 1 says that a provider must include: patient’s name, patient’s date of birth, insured person’s name, patient’s relationship with the insured, insured person’s employer, procedure date, referring provider, health policy number, certificate number, diagnostic code, a procedure code, total fee charged, place of service and whether the claim is for maternity, a road accident or work-related. In addition, insurers can deny claims if a diagnostic code and procedure code is not provided, so it’s vital that you include these in all referrals for diagnostic tests. 

For the regulations in full, visit www.bhec.bm or www.bermudalaws.bm. 

Question: That’s a lot of bureaucracy. Why does a doctor need to provide all of that?

Answer: It might seem like a lot but there are two good reasons. One: the information is vital to understand who was treated, what care was provided and why. 

Without this information, insurers take longer to process a claim; we all want providers to be paid promptly and this information helps. Two: without diagnostic and procedure codes, care will be slowed down if diagnostic tests are ordered. To avoid delays, the information should be provided by physicians on referral.

Question: What does a doctor need from me, the patient?

Answer: Good question. As you can see from the previous answer, your health professional requires quite a bit of information for their billing. To help with this process, you need to take your insurance card to every visit and inform your healthcare provider of any changes to information i.e. address, phone number, insurer, etc. 

This information will help your provider keep track of your medical history as well as knowing how much your insurance will cover. You may have to make co-payments, but these should be a portion of the bill that is not covered by insurance. If you have concerns about the charges, discuss them with the practice first and, if you can’t resolve them, bring the receipt and any other documents to the Bermuda Health Council. 

Question: But my provider always charges me for my visit. Are they breaking the law?

Answer: That’s unlikely. The charge could be a co-pay or due to an exemption. The Regulations allow providers to apply to the Bermuda Health Council for exemptions and/or permission to charge at the time of the visit. Visit our website for the list: www.bhec.bm 

Providers can also charge upfront if it is for a medical appliance, device or product e.g. glasses; if the healthcare professional is not regulated by a statutory body; if you are not insured; or if your coverage cannot be verified at the time of the visit. 

For more information about the Claims Regulations, your responsibility and what they mean for the health system visit: http://www.bhec.bm/health-insurance-act-1970/resources-2/  

Jennifer Attride-Stirling is the CEO of the Bermuda Health Council.