Surgeons' representatives have questioned Bupa's claim of support by the General Medical Council (GMC) for its knee surgery review procedure.
They also allege the health insurer's process has all but broken down in Northern Ireland, due to lack of participation by surgeons, and suggested surgery rates faced by the provider were not out of line with the NHS.
However Bupa expanded on its guidance from the GMC, saying it was told ‘no medical conflict' existed and also denied the process has been changed in Northern Ireland.
It has also sent out a letter to 1,400 Bupa recognised orthopaedic surgeons further explaining the process and contesting criticisms.
Surgeon's representatives, led by the Federation of Independent Practitioner Organisations (FIPO), British Orthopaedic Association (BOA) and British Association for Surgery of the Knee (BASK) have contested Bupa's decision to introduce reviews of all referrals for arthroscopic knee surgery.
Having previously called for policyholders to be informed about the process, the latest statement to COVER noted that 'the GMC has been clear about the question of distant ‘reviews' of clinical decisions.
'This does happen in certain situations (insurance or benefit claims), but when reviewing another consultant's considered opinion and in a proactive clinical situation any medically-trained person who counteracts that decision will need to have a very full knowledge of the case.'
It added that: 'Any doctor providing pre-authorisation denials of treatment must ensure their report is based on all necessary information and if this is not available, he or she ought to decline to comment.
'In addition, their report would need to distinguish between meeting the funding criteria and clinical indications for arthroscopy, as the two will not always be the same.'
The bodies also suggested that Bupa has had to amend its scheme in Northern Ireland with patients there now being accepted without the pre-authorisation form and that in some cases Bupa has asked for extensive clinical details.
They said this had happened because no surgeons in Northern Ireland had agreed to take part in the scheme meaning patients could not be treated in the private sector there.
This had led to Bupa offering patients £500 to go to the NHS and travel and accommodation to the mainland UK, which has resulted, they claim, in some policyholders seeking legal advice.
Both these points were disputed by Dr Annabel Bentley, medical director at Bupa Health and Wellbeing, who said: "The GMC has reviewed our medical process for knee arthroscopy and confirmed that they have no concerns.
"In fact, they have told us that they can see no conflict with their Good Medical Practice guidance or with any other GMC guidance."
Addressing the question of problems with the scheme in Northern Ireland, she continued: "Since the end of April we have received more than 3,500 requests from across the UK, including Northern Ireland, for the funding of knee arthroscopies for our members.
"The vast majority of funding requests have been authorized without delay. To make things as easy as possible for consultants and their patients, they can send us relevant medical letters and imaging reports to support claims for funding.
"Our members are able to receive their treatment within the NHS if they choose to do so, however so far, no one has taken up this option for knee arthroscopy," she added.
One of Bupa's chief reasons for introducing the review process was significantly higher rates of referral compared to the NHS.
However, the surgeons' bodies argued that 'variation in rates of arthroscopy within different areas in the NHS is more than twofold and thus, any comparisons will depend on the figures chosen.'
'We would contend that treatment in the NHS is being rationed and our consultant survey confirms that over 50% of surgeons feel that Primary Care Trusts (PCTs) are interfering in the process of care.
'There is no reason to lower the standards in the private sector: we should argue, and we have argued, for the improvement of standards and access in the NHS and we are protesting about any undue interference by the PCTs in every way we can,' it added.
Again, Bupa defended its decision and denied it was trying to ration care or lower standards.
"On the contrary, our aim is to ensure our members receive funding for treatment in-line with clinical best practice," Dr Bentley said.
"Bupa has a fiduciary responsibility to its members (we have no shareholders) to ensure that we only fund treatment that is: representative of best practices of the medical profession in the UK; shown through scientific evidence to be effective in improving health outcomes; and clinically appropriate in terms of type, frequency, extent, duration and location."
