Private health insurer provider networks

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Preferred Provider Networks

Private health insurer provider networks

In November 2009, Bupa Australia (encompassing HBA. MBF and Mutual Community) moved to consolidate its three separate preferred provider networks into one. As of 1st April 2010, the funds’ individual preferred provider schemes will be combined into one Bupa Australia network, and physiotherapists in the existing schemes are being asked to apply for membership of this new network.

The benefits of these schemes are obvious to practitioners, they encourage fund members to attend your physiotherapy practice, and provider higher rebates to some clients. But before making any business decision to participate or renew participation in a preferred provider network, there are some questions that you should consider.

Do all of the physiotherapists in your practice want to be members of a preferred provider network?

Private health insurers can join practices to their preferred provider schemes, not individual therapists. This can be problematic if one practitioner wants to join or leave a scheme independent of the other physiotherapists in the practice. The APA believes that individual physiotherapists should be able to make a decision on whether a preferred provider scheme is right for them.

Who decides on the value of your service?

Contracts for preferred provider networks usually require physiotherapists to agree not to charge fund members higher fees than each insurer's mandated amount per service – ie they cap physiotherapy fees. While this amount might be acceptable for some physiotherapists in a practice, a cap means that it might be impossible for more experienced or specialised physiotherapists to charge a higher, more appropriate rate.

Can you negotiate your agreement?

Many contracts for provider schemes are non-negotiable and offered to physiotherapists on a take-it-or-leave-it basis. The APA believes this is inappropriate, and that insurers should use a negotiation process to enter into contracts with APA members.

We also believe that the take-it-or-leave-it nature of the contracts offered by insurers is in contravention of the Trade Practices Act. The APA urges anyone who has been affected by a refusal to negotiate a provider network contract to make a formal compliant to the ACCC. Click here to go the ACCC’s website.

Will the fund support your clinical decision making?

While interference in the clinical aspects of physiotherapy treatment is not something that is common, some funds have been known to write to physiotherapists who are members of preferred provider networks if the practice’s average number of treatments varies from the fund’s recorded averages for the state. Such letters have contained notification that participation in a preferred provider’s network was partially contingent on average services per patient, and notification that the figures would be reviewed in the future. Physiotherapists have interpreted such letters as a suggestion that they have been over-servicing clients.

The APA’s code of conduct strictly prohibits client over-servicing, and the APA does not in any way support the unnecessary provision of a health service. However it is important to properly assess any case where there are grounds for suspicion, and the APA does not believe that it is appropriate to determine if a physiotherapist is over-servicing on the basis of statistics alone. The APA believes that funds should support their members and your clients to get the best possible service for their individual needs. If an insurer suspects that a physiotherapist of over-servicing, an investigation should be undertaken by the appropriate authority.

What the APA has done so far - publications and resources for APA members

Joining a health fund’s provider network is your choice, however the APA doesn’t endorse schemes that cap physiotherapists’ fees. We believe that that artificially lowering remuneration reduces the opportunity for physiotherapists to undertake professional development activities and fails to support the development of rewarding career pathways for physiotherapists. We are also concerned with the market penetration of these schemes in some jurisdictions, which give insurers unprecedented control over fees and service levels in some states.

Over the last 12 months, the APA has taken steps to ensure that physiotherapists are aware of the repercussions of preferred provider networks. These include:

An article in Business in Practice – the PBA member magazine, Issue 4, 2009