Confusion over Ireland’s cross-border healthcare scheme

The Irish Ombudsman has highlighted confusion over the scheme for providing health care abroad.

Ombudsman Peter Tyndall says that some people are confused about the EU cross-border healthcare scheme that provides for medical treatment abroad. He wants more people to be aware of the scheme.

The EU Cross Border Healthcare scheme gives people resident in the Republic of Ireland the option of having public health treatment in another EU country. People use the scheme due to long waiting lists for some publicly funded treatments. The scheme is administered by the HSE, which reimburses the cost of the treatment. Reimbursement is made in line with published rates available from the HSE’s National Contact Point. The patient pays for the cost of treatment in advance.

The Ombudsman said:

“I have received a number of complaints from people who are confused about how the scheme operates or who have had difficulties when trying to reclaim the money they have spent on their treatment. Very often they are vulnerable people who are seriously ill and who have had to travel outside the country to receive much needed medical treatment. I want people to know about the scheme and, together with the HSE, I want to ensure they are fully aware of all the procedures relating to the scheme before they travel.”

The Cross Border Healthcare scheme is different to another scheme that is in existence, the Treatment Abroad Scheme. In general, the Treatment Abroad Scheme covers treatments that are not available in Ireland. The Cross Border Healthcare scheme covers treatments that are publicly funded and available in Ireland.

The Ombudsman has published summaries of three of the complaints his Office has received. The complaints relate to confusion over the administrative code used for treatments or confusion over reimbursement for in-patient and outpatient care. In-patient (or overnight) treatment requires prior approval by the HSE before travelling, and there is an associated code and an agreed cost for each specific treatment. Outpatient or day care treatment does not require prior approval.

Case Study 1: Pensioner denied full refund of cross-border hip replacement operation

A 74 year-old woman complained to the Ombudsman when the HSE did not refund the full cost of her hip operation. The woman had waited over two years on the public waiting list for the operation and had decided to travel to Northern Ireland for treatment under the Cross Border Healthcare scheme. She had paid the full cost of the operation in advance (€12,500 which she had borrowed from a relative) and then sought to reclaim the money from the HSE. However, the pensioner complained to the Ombudsman when the HSE repaid only €10,900 of the cost involved.

The HSE explained that the original approval was based on the information provided by the woman’s consultant. She had originally been approved for a non-standard hip replacement operation. After the woman’s surgery, the Northern Ireland consultant had not confirmed that she had received the more expensive non-standard surgery. The HSE made a payment for a less expensive standard hip replacement operation but committed to having the woman’s medical chart independently assessed to check whether the more complicated procedure had been provided. When the woman contacted the HSE the independent assessment of the medical chart had not been carried out. The HSE accepted that the independent assessment should have been carried out sooner. The HSE apologised to the woman and refunded her the shortfall amounting to €1,600.

Case Study 2: Wrong scheme – wrong information

A woman who had previously been approved for in-patient lymphedema treatment (to control swelling on her legs following cancer treatment) under the Treatment Abroad Scheme (TAS) was initially refused further treatment under that scheme. She was then incorrectly advised to apply for treatment under the Cross Border Healthcare scheme before eventually being approved for treatment under the Treatment Abroad Scheme.

The woman was not informed that she could have appealed the HSE’s initial decision to refuse her TAS application. Instead, the HSE told her to apply for treatment under the Cross Border Healthcare (CBH) scheme. According to the HSE, the treatment she needed was available on an outpatient basis in Ireland. This was incorrect. While outpatient care is available here for some lymphedema patients, the woman required a more intensive form of in-patient treatment for her condition that is not currently available in Ireland. Therefore, her application should have been considered under the Treatment Abroad Scheme rather than the Cross Border Healthcare scheme.

After paying in advance for her treatment abroad under the CBH, she was advised by the HSE that she needed to submit a treating code. There are no HSE treating codes for outpatient care abroad. In desperation the woman turned to her private health insurance that provided a contribution towards the costs. After she complained to the Ombudsman the HSE agreed to refund the balance to her (€2,900). The HSE also agreed to approve future lymphedema treatment for the woman under the Treatment Abroad Scheme and to consider applications for other patients in a similar situation.

Case Study 3: Difference in day care costs versus in-patient care

A man received approval from the HSE for in-patient treatment (involving an overnight stay) for carpal tunnel syndrome in both his hands. The man paid in advance for his in-patient care in a Northern Ireland hospital at a cost of nearly €7,000 but was well enough to leave the hospital on the same day as his operation. Therefore, he was deemed to be a day patient and should have received a refund from the hospital. However, when the man sought a refund from the hospital it was refused. The hospital said that the cost was the same whether he went home the same day or remained overnight.

The HSE could only reimburse the man as a day patient which amounted to just over €2,000. This left him with a shortfall of almost €5,000. When the Ombudsman checked with the Northern Ireland hospital about the variation between day and in-patient charges, the hospital accepted that an error had been made. It agreed to refund the man’s outstanding costs. The HSE could not have been expected to know that the man would be discharged as a day patient having issued approval for him to receive in-patient care. The HSE, in consultation with the Office of the Ombudsman, has altered its approval letter to inform patients of the range of possibilities under the scheme and about their entitlements.

In October 2016 the European Commission published a report on cross-border healthcare use in the EU. The report shows that in 2015 Ireland received:

• 4,599 requests from people seeking information about the scheme
• 216 requests for authorisation to travel, of which 93 were authorised, 15 refused and 85 withdrawn or in admissible.

Ireland reimbursed a total of €448,458 under requests for prior authorisation.