Guidance

Upfront charging operational framework to support identification and charging of overseas visitors

Updated 7 January 2021

This framework supplements the guidance on implementing the overseas visitor charging regulations (the main guidance). Definitions of terms such as ‘overseas visitor’, ‘relevant service’ and ‘relevant body’ all have the same meanings as in the main guidance.

Providers must comply with all relevant aspects of the main guidance.

1. Executive summary

The National Health Service (Charges to Overseas Visitors) Regulations 2015, as amended, (the charging regulations), place a legal obligation on any organisation providing relevant services to an overseas visitor to make and recover charges from the person liable where no exemption from charge category applies. To undertake this duty organisations are required to establish whether a person is an overseas visitor to whom charges apply, or whether they are exempt from charges.

Where charges apply, they must be recovered in full in advance of providing treatment, unless doing so would delay the provision of treatment that is clinically assessed as either immediately necessary or urgent. Since recovery of costs after the provision of treatment is often difficult, this action is critical to ensure that finite NHS resources are protected at a time of financial challenge for the NHS.

This document has been developed with input from NHS Improvement, to set out a framework on the practical steps and key considerations necessary for providers to implement cost recovery and meet the legal requirement to charge upfront.

It reiterates that the most vulnerable, chargeable patients always have access to care, whenever they need it, regardless of advance payment. This is because treatment that is immediately necessary, for example maternity or emergency treatment, or other treatment that cannot safely wait until the patient can reasonably be expected to leave the UK (known as ‘urgent’ treatment), is never to be delayed or denied.

For charging to operate effectively, it is essential that providers implement and embed cost recovery at all levels of the organisation, so that the NHS can successfully recover costs from those patients who should be paying for relevant services.

Section 4 sets out the central role of providers in creating a suitable structure to oversee and implement cost recovery processes, ensuring staff are aware of and receive appropriate training to carry out their roles and responsibilities in the recovery of costs from overseas visitors.

Providers should ensure they have in place either a designated specialist for cost recovery, such as an overseas visitor manager (OVM) (supported by an administrative team), or a suitable person/team as part of existing roles.

Section 5 of this framework sets out the key role of the OVM. This section also sets out the role of the clinician, whose focus is solely on assessing whether the patient requires immediately necessary or urgent treatment. It is not the role of the clinician to identify patients who may be required to pay for treatment.

Sections 6 to 8 set out the steps required to estimate costs for upfront charging purposes and the actions necessary to ensure financial requirements are met, including preparing invoices.

Section 9 sets out a number of clinical case studies to support clinicians when making decisions about whether the care they recommend is urgent or immediately necessary.

2. The framework

2.1 Purpose

This operational framework is intended to be a helpful and practical guide for providers to use to support:

• the upfront charging of overseas visitors, whose treatment is deemed non-urgent or routine; and
• the recovery of charges from overseas visitors, whose treatment is deemed urgent or immediately necessary

2.2 Who this framework is for

This framework has been prepared primarily for the use of those individuals in relevant bodies who have responsibilities associated with the identification and charging of those patients not eligible for relevant services without charge, including:

• OVMs
• patient-facing administrative teams
• administrative staff
• finance managers
• clinicians
• senior responsible officers

2.3 Other guidance and support for implementing upfront charging

This framework is a supplement to the main guidance. Providers must understand and refer to the main guidance when implementing upfront charging.

In addition to the main guidance, a range of additional materials produced by DHSC are available.

E-learning on implementing the charging rules is also available for all staff involved in the cost recovery process, and includes guidance on upfront charging.

This framework applies in England only. Accessing healthcare in Scotland, Wales and Northern Ireland could be different from England. For more information, visit the websites for health services in each country:

• Northern Ireland
• Scotland
• Wales

3. Cost recovery legislation and principles

3.1 The charging regulations

The National Health Service (Charges to Overseas Visitors) Regulations 2015, as amended (the charging regulations) apply to all courses of treatment commenced on or after that date. The charging regulations apply to England only and replace previous regulations on charges to overseas visitors.

The charging regulations place a legal obligation on any organisation providing relevant services to an overseas visitor to make and recover charges from the person liable where no exemption from charge category applies. To undertake this duty organisations are required to establish whether a person is an overseas visitor to whom charges apply, or whether they are exempt from charges.

Relevant bodies are legally required to recover in full charges for services in advance of providing treatment unless doing so would delay the provision of treatment that is clinically assessed as either immediately necessary or urgent. Since recovery of costs after the provision of treatment is often difficult, this action is critical to ensure that finite NHS resources are protected at a time of increased financial challenge for the NHS.

3.2 Exempt services and individuals

Not every overseas visitor is required to pay for healthcare. Some services and categories of visitor are exempt from charging (see Chapter 1 of the main guidance for the full list). In these cases, the treatment should be paid for by the relevant commissioner.

Healthcare for overseas visitors from the European Union (EU), Norway, Iceland and Liechtenstein and Switzerland

From 1 January 2021, most visitors from the EU will continue to access healthcare in the UK on the same basis as before, but some entitlements have changed. Details of how visitors from the EU, and from Norway, Iceland, Lichtenstein, or Switzerland can access healthcare in the UK from 1 January 2021 can be found in the main guidance.

3.3 Vulnerable patients

When operating the charging rules, it is very important that the OVM/patient-facing administrative teams and clinicians consider the position of vulnerable patients who may not be eligible for free care, may be unaware that they are exempt from charging or who may have difficulty providing documentary evidence of their eligibility. This includes those unlawfully resident in the UK.

Not all people who are vulnerable are exempt from charges, however there are exemptions in place for many of the most vulnerable. This includes refugees and asylum seekers and their dependants, children looked after by a local authority, and victims of modern slavery (see Chapter 1 of the main guidance for the full list). Chapter 7 of the main guidance discusses in detail how to consider the position of vulnerable patients.

To ensure all patients who may be vulnerable receive the care and support they need regardless of their eligibility status, providers should work with local stakeholders and wider communities to ensure that availability of healthcare is understood, including those services free to all. They should also ensure that every effort is made to communicate this to all potential patients, including those who can be hard to reach. To do this effectively, local organisations will need to work in partnership to develop effective communication and safeguarding processes.

Safeguarding

OVMs/patient-facing administrative teams and other frontline staff are strongly encouraged to speak to their safeguarding leads if, in the course of their work, they are concerned about the welfare of any patient. The OVM/patient-facing administrative team should build constructive relationships with local agencies that support people in various types of need, or seek advice and information from relevant national agencies and organisations.

Maternity services

All maternity services must be treated as being immediately necessary. No one must ever be denied, or have delayed, maternity services due to charging-related issues. This does not necessarily mean that maternity services are free; the patient may be an overseas visitor to whom charges apply. In such cases, the patient should be informed that treatment will be provided but that costs will be recovered after treatment.

Although a person must be informed if charges apply, in doing so they should not be discouraged from receiving any part of their maternity treatment. It is critical that they are supported to continue with their care and that the provider communicates all payment options to them, for example affordable repayment plans.

OVMs/patient-facing administrative teams should be especially careful to inform pregnant patients that further maternity healthcare will not be withheld, regardless of their ability to pay or their immigration status. These patients should also be made aware that accident and emergency services and primary medical services remain free to all and that they are also exempt from certain other primary medical care services such as, for example, prescription charges.

If at any point a maternity patient ceases to attend planned appointments, safeguarding procedures should apply, with immediate action taken to locate and speak to the individual to discuss any concerns they may have and their options for provision of care. It is important that providers work with other stakeholders in their local communities to embed and enforce effective safeguarding procedures and communicate with potentially vulnerable patients.

Equality and diversity: interpreter services

To ensure that there is effective communication with patients, their relatives and carers, the provider should ensure that there are arrangements in place to provide appropriate communication and interpreter support to those patients whose first language is not English or who may have a sensory impairment/loss affecting communication.

The provider should have in place policies and procedures that meet current national standards for interpretation and translation services for healthcare purposes. The provider’s policies and procedures should clearly set out the responsibilities of all staff members involved and highlight the need for there to be clear and effective communication between all staff involved.

4. Provider role and responsibilities

Providers should ensure that all staff within the organisation are aware of and understand the implications of the legal requirement to charge upfront for treatment that is not immediately necessary or urgent, where no exemption from charge category applies. They should arrange for appropriate training to be given.

Providers will need to ensure they put in place the necessary structures and processes to implement upfront charging, if they have not already done so. Where possible, providers should appoint an executive board member and/or senior responsible officer to oversee the implementation of cost recovery and upfront charging processes and ensure the spirit of the policy is understood and embedded across the organisation at all levels. Executive boards should make cost recovery performance a standing item at appropriate board-level meetings to monitor performance, review implementation and consider any issues that may be affecting performance.

They are advised to appoint a clinical champion to ensure clinicians are fully engaged in the cost recovery process and understand their role in applying the charging regulations is focused on assessing whether a patient requires treatment that is immediately necessary or urgent. The provider should also put in place an individual or team responsible for implementation of charging processes (such as an OVM), at an appropriate level depending on the size of the organisation and the opportunity to recover costs. More detailed information on the roles and responsibilities of OVMs/patient-facing administrative teams and clinicians in particular are set out in sections 5-7.

4.1 Local communications

As well as ensuring staff are aware of and understand their legal obligations under the charging rules, providers should provide robust communications to patients about the charging rules, so they are aware of and understand any impact that these may have on their care. This should include information on the treatment/services that are exempt (see the resources page for examples of posters and template patient letters) but also who they can speak to for more information and support, and how to escalate any complaints or concerns they may have about decisions made regarding their chargeable status or care.

Staff who are responsible for liaising with patient groups and forums should also ensure that cost recovery is an ongoing item in discussions.

Providers should also work with their local primary care practices and commissioners to help support the process of identifying patients who may need to pay for their treatment.

4.2 Monitoring

The public sector equality duty requires public bodies to have due regard to the need to eliminate discrimination, advance equality of opportunity and foster good relations between people with a protected characteristic (age, disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation) and those who do not.

Providers should therefore ensure that the way they provide services to the public and the way staff are treated reflects individual needs and does not discriminate against individuals or groups on any grounds, both as employers and when making policy decisions and delivering services.

Providers should ensure that monitoring arrangements are in place to assess the implementation of the charging regulations for overseas visitors and take steps to improve implementation where required (see section 8).

Providers should ensure there are ongoing checks for unintended consequences that may arise as a result of upfront charging and put in place steps to prevent these to ensure patient safety and quality of care is maintained at all times.

5. Patient pathway

The effective operation of the charging rules depends on staff at all levels, including senior management and clinicians, being aware and supportive of OVMs/overseas teams. If a specific OVM/overseas team is not in place, relevant administrative/patient-facing staff in the patient pathway should be provided with the necessary training, resources and support to enable them to fulfil the providers’ legal requirements.

5.1 Identifying eligibility for free care

Providers are legally obliged to establish whether or not a patient is eligible to relevant services without charge. This is primarily the responsibility of the OVM/patient-facing administrative team, but frontline staff such as receptionists can play an important part in this process by passing information on a patient’s status to the OVM/patient-facing administrative team, where the patient has given consent for this to happen.

We recommend that the following baseline question is used when patients present, for example at reception:

‘Where have you lived in the last 6 months?’

Other wording is acceptable as long as the meaning of the question remains the same and the same question is asked of all people whose chargeable status is not known. The baseline question needs to be asked every time a patient begins a new course of treatment.

Whether they have lived in the UK or elsewhere, the individual should be asked to demonstrate wherever possible they are entitled to relevant services without charge, whether by virtue of an exemption, by being ordinarily resident or having the immigration status of indefinite leave to remain, having paid (or had waived) the immigration health surcharge or under a reciprocal healthcare arrangement.

Further information on demonstrating and recording entitlement to relevant services without charge is available in the main guidance (pdf). A list of countries that have agreed reciprocal healthcare arrangements with the UK can be found in chapter 10: Other reciprocal healthcare agreements and international obligations.

If relevant documentation or other evidence is not provided to or obtained by the OVM/patient-facing administrative team, the patient may not be eligible for relevant services without charge.

Further information about identifying patients is available in the main guidance and in the resources for NHS trusts to help manage overseas visitors and migrant charging.

OVMs/patient-facing administrative teams should seek to identify patients who may not be eligible for free care in advance of placing them on planned outpatient and inpatient waiting lists. If they do not already, providers should consider factors that may indicate ineligibility, such as not being registered with a GP or not having an NHS number, as a prompt to indicate which are most likely to need further enquiry. The OVM/patient-facing administrative team can use this information from the Summary Care Record application (see chapter 5 of the main guidance), past records and additional information sought from the patient, to establish the patient’s chargeable status.

OVMs/patient-facing administrative teams should also use a daily electronic report to advise them of patients who have been admitted to the provider through a non-elective route. The OVM/patient-facing administrative team should then check the patient’s status and speak to those from whom they may need more information in order to confirm if they are eligible for free care.

It is important to note that it is a legal requirement for NHS trusts and foundation trusts to record a patient’s chargeable status against their NHS record. A patient’s status must be recorded via the Summary Care Record application (see paragraphs 5.24 to 5.31 of the main guidance and module 9 of the e-learning).

The chargeable status ‘flag’ will be visible to all who view a patient’s record on NHS Spine, which supports the IT infrastructure for the NHS in England. Only those with RBAC code B0259 will be able to view the detail behind the flag and only those with RBAC code B0266 will have edit functionality. In order to receive RBAC B0266, OVM/patient-facing administrative teams will need to complete all e-learning modules and apply to have RBAC code B0266 added to their smartcards via their provider’s local registration authority. The chargeable status flag is stored on the personal demographics service (PDS) on Spine alongside other NHS patient details, such as name, address, date of birth and NHS number.

5.2 Determining when as overseas visitor patient can reasonably be expected to leave the UK

For treatment that is not immediately necessary, it is the role of the OVM to establish when a patient can reasonably be expected to leave the UK and to enter this information on the clinical patient assessment form. Clinicians will need to know this information in order to decide if the patient’s need for treatment is urgent or if it can safely wait until they leave the UK.

Documented migrants

As a condition of their entry to the UK, short-term visitors are required to have sufficient funds available to finance their stay, and that of any dependants, as well as the onward or return journey. Many documented migrants have return journeys booked when they enter the UK. If they need treatment before that return date but claim that they cannot pay for it in advance, they should arrange an earlier return journey before, in the opinion of a clinician, the treatment would become necessary. If an earlier return journey would not be reasonable, and treatment is urgent, care should be provided when clinically appropriate, and debts recovered.

Those without return journeys booked are expected to leave the UK for the treatment needed, again, unless it would not be reasonable to do so. As a final resort, the date at which their visa requires them to leave the UK should be used as the date of return.

Undocumented migrants

For undocumented migrants, including failed asylum seekers (some of whom will be chargeable), the likely date by which the person can reasonably be expected to leave the UK may be unclear, and will have to be assessed on a case-by-case basis. Those for whom there is no viable place of return, for example because there are travel or entry clearance restrictions in their country of origin, or for whom there are other conditions beyond their control preventing their departure, should not reasonably be expected to leave the UK until such issues are resolved.

In some cases, it will be particularly difficult to estimate the date at which they can be reasonably expected to leave the UK. Relevant bodies may wish to estimate that such patients will remain in the UK initially for 6 months, and the clinician can then consider if treatment can or cannot wait for 6 months, bearing in mind the definitions of urgent and non-urgent treatment given above. However, there may be circumstances when the patient is likely to remain in the UK longer than 6 months, in which case a longer estimate can be used.

5.3 Clinician assessments of overseas visitor patients

It is the clinician’s role to provide appropriate healthcare for patients and make decisions on their treatment based on their clinical needs. The charging regulations do not change that.

Once the OVM/patient-facing administrative team has established that the patient is chargeable and the date by which they could reasonably be expected to have left the UK, it is the responsibility of clinicians to decide whether the patient’s treatment is immediately necessary, urgent or non-urgent.

Only clinicians can make an assessment of the urgency of treatment; the final decision lies with the lead treating clinician.

Immediately necessary treatment is that which a patient needs promptly to:

• save their life
• prevent a condition from becoming immediately life-threatening
• prevent permanent serious damage from occurring

Urgent treatment is that which clinicians do not consider to be immediately necessary, but which nevertheless cannot wait until the person can be reasonably expected to leave the UK. This means that the longer a patient is expected to remain in the UK, the greater the range of their treatment needs that are likely to be regarded as urgent.

If the person is unlikely to leave the UK for some time (which will be the case for some undocumented migrants), treatment which clinicians might otherwise consider non-urgent (for example, certain types of elective surgery) is more likely to be considered by them as urgent. It may not always be clear when a person can reasonably be expected to leave the UK.

Clinicians may base their decision as to whether treatment can reasonably wait until the expected date by which the patient can leave the UK on a range of factors, including:

• the pain or disability a particular condition is causing
• the risk that delay might mean a more involved or expensive medical intervention being required
• the likelihood of a substantial and potentially life-threatening deterioration occurring in the patient’s condition if treatment is delayed until they leave the UK

Non-urgent treatment is routine treatment that can wait until the date a patient can reasonably be expected to leave the UK.

The clinician will need to make initial assessments based on the patient’s symptoms and other factors and to conduct further investigations to make a diagnosis. Although these initial assessments and investigations will be included in any charges (unless an exemption applies), they cannot be withheld even if a payment for treatment has not been received upfront for the cost of the assessment.

While urgency of treatment is a matter of clinical judgement, this does not mean that treatment should be unlimited – there may be some room for discretion about the extent of treatment and the time at which it is given. In many cases, a patient undergoing immediately necessary treatment may be able to be stabilised, allowing them to be safely discharged and giving them time to return home for further treatment rather than incurring further avoidable charges. This should be done wherever possible, unless there is a risk that ceasing or limiting treatment would cause deterioration in the patient’s condition.

The clinical team or department should inform the OVM/patient-facing administrative team if a patient is receiving a particular treatment that is exempt from charges, for example if a patient is undergoing diagnosis or receiving treatment for a sexually transmitted disease (see Chapter 1 of the main guidance for the full list).

If a clinician does become aware that a person who has not been identified as chargeable is not ordinarily resident in the UK, they should notify the OVM/patient-facing administrative team. The OVM/patient-facing administrative team can then work with the patient to confirm whether they are eligible for free care and enable the patient to make informed decisions about their treatment and travel plans.

To record their assessment decision, clinicians should complete their section of the clinician patient assessment form and sign and date it. This form includes 4 options, which set out whether treatment:

• is immediately necessary
• is urgent
• is non-urgent – and therefore it is not necessary to provide treatment unless payment is made in advance
• requires further investigation before assessment of urgency can be made

A series of clinical case studies is set out in Section 9 of this guidance to support clinicians when making decisions about whether the care they recommend is urgent or immediately necessary.

Patients who need to be monitored after discharge

The clinician will decide on a case-by-case basis when a patient is fit for discharge and the level of monitoring required post-discharge. As part of the discharge decision, the patient should be assessed for their clinical fitness to travel.

There should be an approved discharge planning process for managing the discharge/transfer of patients, including arrangements for clinically necessary post-discharge monitoring that is implemented and kept under review. The costs to the patient of that on-going monitoring must be made clear to the patient.

5.4 Confirming to the patient that charges apply

Once the urgency of treatment a patient requires has been categorised, it is the role of the OVM/patient-facing administrative team to discuss with the patient their options:

• if the patient has not paid/refuses to pay/is unable to pay upfront and their treatment is not immediately necessary or urgent, they should be informed that they are not entitled to receive treatment
• if the patient has not paid/refuses to pay/is unable to pay and treatment is deemed immediately necessary or urgent, they should be informed that they will be provided with treatment, but that the costs will be recovered, with any debts pursued where appropriate as per the usual cost recovery process

The OVM/patient-facing administrative team should act appropriately when requesting payment, taking into consideration the particular circumstances of the patient – for example, when dealing with a vulnerable patient who may leave the hospital if it appears they will be charged. If required, the OVM/patient-facing administrative team will be responsible for generating a referral to the safeguarding team, collaborating with the lead clinician.

Once the clinician patient assessment form is completed and signed by both the clinician and the OVM/patient-facing administrative team, the OVM/patient-facing administrative team should:

• process the form, updating the data record as appropriate
• communicate with the patient, including full, clear signposting on how they can challenge the provider on any decision they disagree with
• deal with upfront charging decisions as necessary

6. Upfront payments

6.1 Cost estimates: pricing schedule

Following the categorisation of treatment, the OVM/patient-facing administrative team should inform the patient of the estimated costs of treatment.

A list of indicative prices has been developed for guidance purposes to support upfront charging. These are not mandatory and not designed to replace existing tariff-based pricing practice where it is felt that the provider has a system in place and agreed with their commissioner that creates more accurate estimates than these indicative prices. This national indicative price list will stay under review and NHS Improvement will ensure that any national pricing changes/adjustments are reflected as required.

The OVM/patient-facing administrative team should explain that the charge at this point is an estimate, based on the national tariff, and that the final invoice may be adjusted, with either a refund provided if the estimate is higher than the final cost, or further payment taken if the estimate is lower than the actual cost, which is dependent on a number of factors, including the condition of the patient and any additional treatment or extended length of stay required.

6.2 Requesting payment

Non-urgent treatment

If the patient is not eligible for relevant services without charge, the OVM/patient-facing administrative team should advise the patient that they are liable and need to pay for treatment upfront and in full.

Immediately necessary or urgent treatment

Where the patient is found to be liable, the OVM/patient-facing administrative team should advise the patient of estimated costs at the earliest opportunity after the initial clinician’s assessment (establishing whether the patient does or does not require immediately necessary or urgent treatment), ensuring the patient’s clinicians are also aware.

7. Methods of payment

Each provider should ensure they can take payment using:

• credit/debit card (in person and over the telephone)
• bank transfers
• cash (ensuring appropriate cash-handling processes are in place and adhered to)
• payment plans

In cases where the patient has medical health insurance and does not require immediately necessary or urgent treatment, direct payment should be taken from the patient. The patient should be given sufficient paperwork to enable them to pursue a claim for reimbursement from their insurer. If their cost recovery policy and processes allow, the provider may alternatively seek direct payment from the insurer prior to any treatment.

8. Withholding treatment for non-payment

If a patient refuses to pay, the OVM/patient-facing administrative team should inform them that they will not receive treatment as treatment of their condition has been assessed by the clinician as not being immediately necessary or urgent.

For elective treatment that is not immediately necessary or urgent, where they have been referred for treatment by a GP, the OVM/patient-facing administrative team should send the patient the patient chargeable letter and send their GP the advice to doctors and dentists letter, informing them that the patient is not eligible for free treatment.

Patients who are unable to pay for care deemed non-urgent or not immediately necessary, such as those on low incomes, should be signposted to support groups such as the British Red Cross, their embassy, the Home Office (voluntary return), Citizens Advice or other local support group.

Providers must also ensure they have in place clear, robust and accessible processes for patients who wish to make a complaint or challenge the decision made by the clinician that treatment of their condition is not immediately necessary or is non-urgent. OVMs/patient-facing administrative teams need to ensure that they and patients charged for NHS services are aware of these procedures and that they are communicated and followed at all times.

9. Final costs and invoicing

9.1 Invoicing and payment arrangements

The upfront charge should be calculated using the NHS Improvement overseas patient upfront tariff (see section 6.1) or the provider’s own pricing method, where this creates more accurate estimates than these indicative prices.

The OVM/patient-facing administrative team or finance team should raise the invoice prior to commencement of treatment. The invoice should clearly set out the reasons for the charge. The invoice should also set out a high-level explanation of the charge. The invoice should then be issued to the patient as soon as possible, and the patient informed that treatment will not progress until payment is received.

Chargeable patients should be informed that a post-discharge adjustment will be made if necessary (further invoice or refund) once the full price related to the fully coded treatments has been calculated, based on the NHS national tariff.
Payment can be taken using credit/debit card payments, bank transfers, cash or through direct debit or standing orders (see methods of payment).

Where a patient has personal insurance cover, it is the patient who is liable for payment of costs and responsible for settling invoices. The provider should ensure the patient has sufficient paperwork to pursue a claim for reimbursement from their insurer.

9.2 Post-discharge adjustment charge

The finance team should finalise the invoice by completing the required actions (which will include but not be limited to the reconciliation between the estimated invoice and the fully coded invoice). This action can be fulfilled by OVMs/patient-facing teams if they have the capability and resources to do so.

The clinical coding of the overseas visitor’s patient record should be completed in a timely way to ensure any adjustment invoice can be issued as soon as possible after discharge to increase the chances of payment.

Once coding is complete, the fully coded charge can be established. It can then be compared with the upfront invoice raised previously. The adjustment invoice or credit note should clearly set out this calculation, setting out details of final charge on the face of the invoice, together with the original invoice value. It is important that references are included on the invoice that link it back to the original upfront invoice.

If a credit is required, the invoice and the payment on the provider debtor’s system should be unmatched so that they become visible again on the sales ledger. A credit note/journal for the adjustment amount should be raised and processed against the original invoice/payment. The process is set out in the guide to completing the NHS debtors spreadsheet.

9.3 Payment terms, chasing unpaid invoices and debt collection process

On all invoices raised, payment terms should be clearly stated and should maximise the chances of debt recovery, together with clear information related to methods of payment, which should be as simple and flexible as possible. Additional information on the escalation process in relation to debt collection should also be included.

Payment of the invoice should be requested as soon as possible (according to provider policy on payment terms). Where payment has not been made in the specified timescale, the escalation process to recover the debt should be implemented.

Where payment plans are entered into, providers should ensure that they are set at a level that maximises the chance of a reasonable return within a reasonable time frame.

The debt recovery team will need to ensure the quick, efficient recovery of outstanding debt, although the OVM/patient facing administration team may do their own debt recovery in some providers.

For non-UK patients subject to immigration control, if the debt is over £500 and outstanding for 2 months or more, without a reasonable payment plan in place, the patient must be referred to the Home Office via DHSC. The Home Office inputs the patient details into its systems to ensure that the patient’s status is recorded. The Home Office can then use that data to deny any future application to enter or remain in the UK that the person with the debt might make. The clinical coding team will need to support the OVM/patient facing administration team by assisting with urgent coding of liable patients.

It is therefore important to ensure that any arrangements for staggered payments are realistic to reduce the need for the patient being placed on the Home Office record. However, a repayment plan should not be used solely to avoid being placed on the debtors list.

Where it is clear that a person is destitute or genuinely without access to any funds, a relevant body can conclude that it is not cost-effective to pursue payment and write it off in their accounts. This is not a waiver nor extinction of the debt and the written-off debt remains on the relevant body’s records and can be recovered.

9.4 Risk-share arrangements with commissioners

Risk-share arrangements with commissioners must be used in the case of treatment deemed by clinicians to be immediately necessary or urgent (for category D and F patients) – those cases where payment is not received upfront and in full in advance of treatment (see NHS England’s resources for CCGs).

The Finance team will need to ensure that any year-end adjustments for risk share in accurate and invoicing complete.

10. Performance management

10.1 Capturing key data

Although there are no new national data requirements as a result of the updated charging regulations, we recommend providers record:

• number of chargeable patients treated, both elective and non-elective
• number of patients identified as not eligible for relevant services whose non-urgent or not immediately necessary treatment did not go ahead as payment was not received or who have decided not to seek treatment following being identified as chargeable
• how much income has been received through upfront charging
• the level of debt from chargeable patients
• how much has been written off
• the value of debts that are unpaid and not recoverable

This information, if it can be collected, should be used by providers to assess how effectively they are implementing upfront charging.

The infomatics team will need to support the OVM/patient facing administration team with predictive reports and ensure, where possible, that the Patient Administration System has a relevant flagging system for patients not eligible for free care.

11. Clinical case studies

The clinical case studies below are to support clinicians when making decisions about whether the care they recommend is urgent or immediately necessary. For the purpose of this guidance, the case studies refer to patients who are directly chargeable. They relate solely to the clinician decision-making process and not to the processes undertaken by OVM/patient-facing administrative teams to identify or charge the patients.

11.1 Case study 1: ED (emergency department) – non-elective pathway

A patient presents to the ED via ambulance with severe chest pain. The patient is a chargeable overseas visitor:

• following assessment by the clinician the patient is diagnosed with severe angina and a myocardial infarction (heart attack) and on this basis treatment is deemed to be immediately necessary
• the clinician decides that an emergency coronary angioplasty procedure is required
• following the emergency coronary angioplasty procedure, the patient is transferred to the critical care unit for high-dependency observation and management
• the patient stays in hospital until medically fit for discharge

Overseas visitor regulations: considerations

• only clinicians can make an assessment as to whether a patient’s need is immediately necessary
• the clinician has decided that treatment in this instance is immediately necessary to save the patient’s life
• as treatment is immediately necessary the date at which the patient can be reasonably expected to leave the UK is irrelevant
• it should be noted that treatment is not made free of charge as a result of being immediately necessary. The admission and coronary angioplasty procedure is chargeable and will be included in any charges
• once stable the patient can be interviewed by the OVM/patient-facing administrative team, who can then begin the process of charging the patient for the treatment received
• following treatment, the clinician will decide on a case-by-case basis whether the patient is fit for discharge and the level of monitoring required post-discharge
• prior to discharge the patient should be stabilised to enable them to be fit to return home for ongoing treatment
• the clinical team will inform the patient of the treatment they have received, provide a written discharge letter and advise them to contact their local healthcare practitioner as soon as possible on their return to their home country. A letter is sent to their GP advising of the treatment and discharge arrangements
• the patient should be assessed for their clinical fitness to travel, either travelling independently or using in-flight medical services arranged at their own expense, or seek Home Office support to travel home
• once the patient is stabilised and deemed to be medically fit for discharge, the patient should then, where possible, travel to their home country for further ongoing treatment

11.2 Case study 2: outpatients – elective pathway

A chargeable patient has been referred by a GP to the orthopaedic clinic with an arthritic hip:

• the patient is identified as being chargeable by the OVM/patient-facing administrative team between being referred and attending their first outpatient appointment with the consultant
• the OVM/patient-facing administrative team also establish that there are no barriers for the patient leaving the UK and the patient can be reasonably expected to do so in around 3 months’ time
• the OVM/patient-facing administrative team inform the consultant of when the patient can be reasonably expected to leave the UK
• the consultant assesses the patient and advises them that they would benefit from a hip replacement. However, they deem that treatment to be non-urgent. They then complete the clinician patient assessment form, which is returned to the OVM/patient-facing administrative team
• the OVM/patient-facing administrative team explains the decision to the patient and provides an estimate of costs for a hip replacement procedure. The OVM/patient-facing administrative team explains that the patient will have to agree to upfront payment for the procedure, ahead of any clinical intervention, or wait until they return home to receive treatment

Overseas visitor regulations: considerations

• it should be noted that treatment is not made free of charge as a consequence of being referred by a GP or having an NHS number
• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• it is important the first consultant assessment goes ahead to ensure there are no reasons why the treatment should be deemed urgent or immediately necessary
• the clinician decides that treatment is non-urgent as it can safely wait until the patient returns home in 3 months’ time

11.3 Case study 3: dialysis

A chargeable patient attends the ED presenting with acute renal disease requiring dialysis 3 times a week:

• following clinical assessment and admission, the consultant advises that the patient requires urgent dialysis to prevent their illness from causing any further renal damage or risk to life
• the OVM/patient-facing administrative team identifies the patient as chargeable and asks the consultant to complete a request for advice from dentist/doctor form. The consultant determines that the treatment, and ongoing dialysis programme, is immediately necessary as it is needed to prevent the patient’s condition from becoming life-threatening
• the OVM/patient-facing administrative team informs the patient that they should pay for their treatment, however the provider will not withhold treatment should they find themselves unable to pay

Overseas visitor regulations: considerations

• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• despite dialysis treatment being planned and routine, denial of this treatment would result in serious worsening of the patient’s condition within a matter of hours. Therefore the treatment should be considered immediately necessary
• as treatment is immediately necessary the date on which the patient can reasonably be expected to return home is irrelevant

11.4 Case study 4: emergency pathway

A patient attends the ED having an acute exacerbation of their long-standing asthma:

• in order to stabilise the patient, immediately necessary treatment is required and delivered in the ED. A clinical decision is made to admit the patient in accordance with the asthma pathway. The patient is informed they will be required to remain in hospital overnight
• as the patient was having difficulty breathing on arrival in the ED, the clinical team assessed the patient as requiring immediately necessary treatment to prevent life-threatening deterioration of their health. Treatment to stabilise the patient was commenced immediately and the agreed asthma protocols followed to stabilise the patient
• the following day the patient is reviewed and identified as much improved and therefore fit for discharge. The clinical team inform the patient of the treatment they have received, provide a written discharge letter and advise them to contact their local healthcare practitioner as soon as possible on their return to their home country
• the OVM/patient-facing administrative team identifies the patient as chargeable once they have been admitted, and in a fit state to be interviewed. The patient is presented with an invoice for treatment received, however no decision is required from clinicians as they have already made the decision to discharge the patient

Overseas visitor regulations: considerations

• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• clinical treatment is immediately necessary so arrangements must be made to treat the patient
• as treatment is immediately necessary the date on which the patient can be reasonably expected to leave the UK is irrelevant

11.5 Case studies 5 and 6: skin cancer and bunions

The scenarios in case study 5a and case study 5b are identical, except for the length of the time before the overseas visitor can be reasonably expected to leave the UK. This difference, however, means that treatment is urgent in case study 5a, as the overseas visitor cannot reasonably be expected to leave the UK to receive treatment that is needed to keep them safe. In case study 5b treatment is non-urgent, as it can safely wait until the overseas visitor can leave the UK for treatment.

Case studies 6a and 6b also show the importance of clinicians knowing and bearing in mind the date on which the overseas visitor can reasonably be expected to return home, when deciding whether treatment is urgent or non-urgent.

11.6 Case study 5a: skin cancer

A chargeable patient has been referred by a GP to the dermatology department with squamous cell carcinoma:

• the patient is identified as being chargeable by the OVM/patient-facing administrative team. The OVM/patient-facing administrative team also establish that the patient is an undocumented migrant who is unlikely to leave the UK in the next year
• the consultant assesses the patient and decides that they should be treated with cryotherapy and that this treatment is urgent
• the OVM/patient-facing administrative team informs the patient that a charge will apply for treatment, however the provider will not withhold treatment should they find themselves unable to pay

Overseas visitor regulations: considerations

• it should be noted that treatment is not made free of charge as a consequence of being referred by a GP, or having an NHS number
• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• it is the role of the OVM to determine when the patient can be reasonably expected to leave the UK and inform the lead treating clinician of this. In this case there is a high chance that the patient is not going to leave the UK for the foreseeable future as they have an outstanding immigration application and have lived in the UK for many years
• the clinician decides that treatment is urgent because it cannot safely wait until the overseas visitor can leave the UK, which is indeterminate

11.7 Case study 5b: skin cancer

A chargeable patient has been referred by a GP to the dermatology department with squamous cell carcinoma

• the patient is identified as being chargeable by the OVM/patient-facing administrative team. The OVM/patient-facing administrative team also establish that the patient can reasonably be expected to leave the UK within 6 weeks
• the consultant assesses the patient and decides that they would benefit from cryotherapy. However, they deem this treatment to be non-urgent. The consultant completes the clinician patient assessment form, which is returned to the OVM/patient-facing administrative team
• the OVM/patient-facing administrative team explains the decision to the patient and provides an estimate of costs for cryotherapy. The OVM/patient-facing administrative team explain that the patient will have to agree to pay upfront for the procedure, for any clinical intervention to go ahead

Overseas visitor regulations: considerations

• it should be noted that treatment is not made free of charge as a consequence of being referred by a GP, or having an NHS number
• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• it is the role of the OVM to determine when the patient can be reasonably expected to leave the UK and inform the lead treating clinician of this. In this case the patient is visiting family in the UK and there is nothing to prevent them leaving the UK
• the clinician decides that treatment is non-urgent because it can safely wait until the overseas visitor can reasonably be expected to leave the UK

11.8 Case study 6a: bunions

A patient attends a community podiatrist clinic with sizeable bunions:

• the treating podiatrist assesses the patient and decides that they need surgery to get rid of their bunions. The podiatrist refers the patient to be treated with an osteotomy
• the OVM/patient-facing administrative team subsequently interview the patient and determine that they are chargeable. The OVM/patient-facing administrative team also establish that the patient is an undocumented migrant whose case for return is currently being considered by the Home Office and is unlikely to be resolved in the next 6 months
• the OVM/patient-facing administrative team fill in the relevant parts of the clinician patient assessment form, give this to the podiatrist and explain the situation. The podiatrist decides that the treatment is urgent because it is likely that, if untreated for a long period, the condition will worsen, causing significant pain to the patient and impairing their ability to walk
• the OVM/patient-facing administrative team informs the patient that they should pay for their treatment, however the provider will not withhold treatment should they find themselves unable to pay Overseas visitor regulations: considerations
• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• the clinician decides that treatment is urgent because it cannot safely wait until the overseas visitor leaves the UK
• it is the role of the OVM to determine when the patient can be reasonably expected to leave the UK and inform the lead treating clinician of this

11.9 Case study 6b: bunions

A patient attends a community podiatrist clinic with sizeable bunions:

• the treating podiatrist assesses the patient and decides that they need surgery to get rid of their bunions. The podiatrist refers the patient to be treated with an osteotomy
• the OVM/patient-facing administrative team subsequently interview the patient and determine that they are chargeable. The OVM/patient-facing administrative team also establish that the patient is visiting family in the UK and can reasonably be expected to leave the UK in the next 2 weeks, even though there is a longer period remaining on their visit visa
• the OVM/patient-facing administrative team fill in the relevant parts of the clinician patient assessment form, give this to the podiatrist and explain the situation. The podiatrist decides that the treatment is non-urgent
• the OVM/patient-facing administrative team explain the decision to the patient and provide an estimate of costs for osteotomy. The OVM/patient-facing administrative team explain that the patient will have to agree to pay upfront for the procedure, for any clinical intervention to go ahead

Overseas visitor regulations: considerations

• only clinicians can make an assessment as to whether a patient’s need for treatment is immediately necessary, urgent or non-urgent
• the clinician decides that treatment is non-urgent because it can safely wait until the overseas visitor leaves the UK
• it is the role of the OVM to determine when the patient can be reasonably expected to leave the UK and inform the lead treating clinician of this