NHSiS guidance manual for overseas visitors

NHSiS Manual of Guidance: Overseas Visitors

Chapter 7: Financial Control	Statutory/Manual References
General
1. The patient's need for care must always take priority over NHS charges.
Value Added Tax
2. NHS charges for treatment are exempt from VAT.
Funding of overseas visitors NHS care costs
3. The cost of NHS hospital service care under these provisions is met by NHS Trusts and DMUs from the contract income they receive from HBs. This is reflected in HBs general annual allocations.
Principles
4. HBs, NHS Trusts and DMUs are responsible for:	Appendix A & 1989 Reg 2
i. making and recovering NHS charges, as appropriate;
ii. determining NHS charges for overseas visitors on an appropriate commercial basis;
iii. securing deposits equal to the full cost of the anticipated NHS treatment (see iv below); and
iv. failing 4iii above:
- obtaining guarantees;
- only undertaking NHS treatment which has immediate clinical need; and
- *not* initiating any elective NHS treatment until such time as 4iii above is satisfied.
5. There are no powers within the Regulations to waive the collecting of NHS charges for the treatment of overseas visitors when they are due. HBs, NHS Trusts and DMUs should consider on a case-by-case basis whether a deposit should be required. Deposits should be equivalent to the full estimated cost of the hospital charges which will be payable. Deposits should be collected as soon as practical, in consideration of the individual circumstances of each case.
6. The procedures for assessing NHS charges on a commercial basis and collecting them should be consistent with the HBs or NHS Trust Standing Financial Instructions and supporting accounting procedures.
7. The NHS Trust or DMU Director of Finance or appropriate officer should ensure that a detailed overseas visitor tariff is compiled before the beginning of each financial year. The Director of Finance, with the agreement of the NHS Trust Chief Executive, or DMU General Manager must decide who in the organisation will be responsible for the presentation of individual NHS accounts, the collection of payments and the issue of receipts in respect of overseas visitor charges. The Director of Finance will need to be satisfied that appropriate systems are in place to ensure the prompt identification of overseas visitors and to secure income.
8. There may be occasions (for example, following a heart attack) when care is required for an overseas visitor who is liable for NHS charges but who has no funds to pay. Where care is administered to prevent a life threatening situation, the NHS hospital should provide such treatment as is clinically required to stabilise the patient sufficiently to allow them to return safely to their country of residence for continuing care. There will be occasions where a patient's discharge from hospital is followed by a readmission for related treatment. Each case should be considered on its merits as regards liability for NHS charge.	Chapter 1 (paragraphs 6 & 7)
9. The general policy set out in paragraph 8 should be implemented on the basis that:
i. the NHS is primarily for those ordinarily resident in the UK;
ii. hospitals do *not* incur additional expenditure that they cannot recover; and
iii. patients receive the sufficient level of NHS treatment to enable them to return safely to their country of residence for continuing care.
Note: Clinical notes should ensure that in cases that require financial write-off it will be possible to confirm that the NHS treatment given was regarded as immediately necessary.
Patient Transport
10. Overseas visitors are subject to the NHS normal contracting and payment procedures for *non-emergency patient transport services (PTS). In such cases where there is a medical need for emergency health service transport for overseas visitors, providers should make such arrangements. The costs of non*-emergency PTS incurred should then be included in:
i. the NHS invoice issued to the patient; or
ii. where the patient is exempt from NHS charges, in any claim for reimbursement.

Overriding EC Regulations
11. EC Regulations (Article 93 of 574/72) oblige the UK Departments of Health to claim back from other EEA member states the actual cost of NHS care given to overseas visitors who come to the UK specifically for treatment. A EC exemption form E112 or E123 will need to be presented by the overseas patient concerned, and forwarded by the NHS hospital to: Benefits Agency Pensions and Overseas Benefits Directorate Medical Benefits Section Tyneview Park Whitley Road *Newcastle* NE98 1BA.	Chapter 12
12. HBs and NHS Trusts compiling data under EC Regulations, should calculate the NHS charges without any profit element (but including capital charges) and notify DSS, as appropriate.	Chapter 12
Deposits and Bills
13. The administrative procedures for the recovery of NHS treatment costs should be identical, wherever possible, to those for charging private patients.
14. Patients should be required to give an undertaking to pay. That undertaking may be signed by the patient or a 'sponsor'. A model undertaking to pay is at Appendix D.	Appendix D
15. Where a patient is financially supported (sponsored) by a third party, a signed undertaking to pay is required indicating that the third party is/are willingly taking on liability for NHS charges for the patient’s care.	Appendix D
16. Where the sponsor is a Foreign or Commonwealth Diplomatic Mission (Embassy or High Commission), a written undertaking to meet the NHS charges should be obtained, signed by an authorised official of the appropriate Mission. Deposits may also be considered in these circumstances. There is no guarantee that a written undertaking will be honoured. Presentation of interim accounts should help give an indication or otherwise of acceptance on the part of the sponsor Mission.
17. When an out-patient appointment is made for a patient liable for NHS charges, payment should be collected in advance. For out-patients the initial deposit should be the NHS charge for an attendance. Further payment should be sought at the time of any subsequent out-patient procedures on the same or later date - the NHS charges to be calculated in the department where the treatment takes place. Out-patients should receive an account at each attendance.

Liability to Pay
18. Those overseas patients liable for NHS charges should be told of the liability as soon as it is clinically appropriate to do so. In cases where the patient is *unable* to sign the undertaking and a third party decides to take on the role of 'sponsor', and agrees to sign the form to assume the responsibility to meet the NHS charges for the treatment required, it should be made clear to that person (the sponsor) that the NHS charges fall to them (the sponsor) to pay and *not* the patient. It is for them (the sponsor) to resolve any subsequent reimbursement of their financial undertaking with the patient.	Appendix D
19. Exemption from NHS charges arise where a patient is:
i. in the UK in connection with his or her employment on a ship (in which case the liability is the ship-owner's);	1989 Reg 7(a)
ii. in the UK in connection with his or her employment on an aircraft (in which case the liability is the employer's); and	1989 Reg 7(b)
iii. a minor in the UK without parents or guardians - the liability should be explained to the person in whose charge the minor has been left (for example, host, tour leader, head teacher) and the bill handed to that person. Copies should be sent to or provided for the parent or guardian.
Summary
20. Paragraphs 18, 19 and other exemptions apart, the liability for NHS charges is always with the patient, not the next of kin (unless, for example, the patient is a child, or where the patient’s condition makes them incapable of making a considered decision).
Private Medical Insurance cover
21. If a patient has private medical insurance with a known reputable UK company or an international company with offices in the UK, contact should be made by the hospital and/or the patient to establish whether adequate cover is available for the expected NHS charges. In cases where the NHS hospital makes the approach, the patient must be advised.
22. If so, bills should be sent direct to the appropriate insurance company, with copies passed to the patient. Where there is no UK office, the account should be presented to the patient on a weekly basis and again on discharge.
Criminal Injuries
23. A patient who is the innocent victim of a crime of violence in the UK may be eligible to claim compensation from the Criminal Injuries Compensation Board (CICB). In such cases the patient or their representative/sponsor should be so informed. Where a patient or their representative/sponsor decides to pursue such a claim he or she should do so on their own behalf to the: Criminal Injuries Compensation Board 300 Bath Street *Glasgow* G2 4JR (tel: 0141 331 2726)
No NHS charges after 1 years residence
24. The record of the Stage 1 interview will show the date of entry into the UK of the patient (or of another person such as the patient's spouse in whose right the patient could become exempt from NHS charges and who entered the UK at an earlier date). This date should be entered on the patients financial records. No NHS charges should be made for treatment given on or after the completion of 1 years residence. There is no backdated exemption from NHS charges for treatment given before the completion of 1 years residence.	Chapter 8 1989 Reg 4(b)
Accounting
25. Revenue accruing from NHS charges under the Regulations should be identified separately in the annual financial returns submitted to SODoH.
26. In-patient accounts should be presented to patients ( or third party) on a weekly basis and on discharge irrespective of whether a deposit has been paid. Out-patient accounts should be presented on each attendance.
Extra Contractual Referrals
27. For overseas patients referred from another NHS facility, extra contractual referral arrangements will apply.
Overseas Debtors
28. In pursuing overseas debts normal recovery action should be taken using agents, where necessary. HBs and NHS Trusts and DMUs should seek the advice of the appropriate Embassy or High Commission on arrangements for recovering debts in the countries concerned. However, if recovery action is unlikely to be cost-effective, consideration should be given at an early stage to write-off procedures. A lower limit of �5000 per case applies for "write-off" in line with standard financial practice.
Patients sponsored by a Foreign Diplomatic Mission
29. Where an overseas patient’s sponsor is an Embassy or High Commission in London, and where payment is *not* forthcoming, a letter should be sent to the head of the appropriate diplomatic Mission by name, seeking help in settling the debt. If a reply is *not* received within 28 days or the reply is unhelpful and the debt amounts to �5000 or more, copies of all correspondence, including any evidence of sponsorship or undertaking to pay, should be sent under cover of an explanatory letter to:

Immunities Section Protocol Department Foreign and Commonwealth Office Old Admiralty Building *London* SW1A 2AF (tel: 0171 210 6384 or 0171 210 6383.)
asking that they take the matter up on the hospital’s behalf with the appropriate Embassy or Mission.
30. If the position changes the Immunities Section must be notified at once.
31. The FCO will *not* take up cases in which private individuals have *not* fulfilled their own undertakings to pay or when sponsors are other than official foreign government bodies. However, this should *not* prevent recourse to the appropriate Embassy or Mission for advice on steps to recoup NHS charges from a former patient.
Change to Private Patient status
32. Where an overseas patient decides to become a private patient the doctor or dentist should inform the Stage 2 officer who should inform the Director of Finance. The patient’s written undertaking must be obtained to pay NHS charges already incurred and levied in accordance with section 57 of the 1978 Act.	1978 Act S.57