PATIENTS WHO SOUGHT to be reimbursed for legitimate costs they incurred after receiving essential medical treatment abroad were not reimbursed by the health service, an investigation has found.
The probe by the Ombudsman Ger Deering discovered that an “unreasonable and inflexible approach” was used by the HSE in “administering schemes that fund treatment abroad for healthcare which the State is either unable to provide, or unable to provide in a timely manner in Ireland”.
The report, published today and titled ‘In Sickness and in Debt’, notes that “some patients faced a fight to be reimbursed for the legitimate costs they had incurred for necessary treatment they received abroad”.
Many had to borrow money as a result and some fell into debt.
In other cases, approval to receive treatment abroad was “unreasonably refused or delayed”.
There were also instances where the HSE refused to reimburse patients for treatment they had paid for and received abroad.
While Deering said he wished to “make it very clear” the the schemes “in the main… work well”, he added that the “investigation report identifies when the schemes do not work well”.
The investigation focused on those who cannot access necessary healthcare in Ireland, and as a result had to travel abroad for their healthcare.
It discovered that many people “found themselves caught in an administrative impasse when seeking reimbursement from the HSE under three schemes”.
The three schemes in question is the Treatment Abroad Scheme (TAS), the EU Cross Border Directive scheme (CBD) and the Northern Ireland Planned Healthcare Scheme (NIPHS).
The TAS and the CBD are schemes which covers the cost of planned treatment in another country in the European Union (EU) or European Economic Area.
The TAS relates to treatment that is not available in Ireland, or not available in Ireland in a timely manner.
The patient does not pay any money up front, but their application has to be approved by the HSE before the treatment takes place.
The CBD is a scheme for treatment that is available in Ireland, but entitles patients to receive that treatment elsewhere within the EU or European Economic Area.
The patient must pay for the treatment up front and then apply for reimbursement from the HSE.
Patients are only reimbursed whichever is the lesser cost: healthcare abroad or what the healthcare would have cost in the public system in Ireland.
Meanwhile, the Northern Ireland Planned Healthcare Scheme is similar to the CBD and allows access to private healthcare in Northern Ireland and for patients to apply to be refunded the cost.
This was implemented in 2021 as a result of Brexit and has become the predominant scheme for patients seeking treatment abroad.
The main part of the report’s investigation focused on the CBD scheme, but the Ombudsman said all the recommendations for it should be applicable to the NIPHS.
The report found that patients “replaced their fight to get treatment with a fight to be reimbursed by the HSE”.
In a foreword to the report, Deering said: “Those that had borrowed money for their treatment also faced a fight against falling into debt.”
“In many of the cases I saw,” said Deering, “people had borrowed significant amounts of money from family, friends or financial institutions to pay for their treatment with the expectation that they would be able to pay them back when reimbursed by the State.
“When a refund was subsequently refused these patients effectively exchanged the anxiety and worry associated with their illness for a new stress of dealing with a debt incurred while accessing a treatment which they were entitled to receive, but could not access, within the State.”
Deering added that patients felt the scheme to be “absolutely unforgiving and lacking in empathy when it came to administrative or pathway errors”.
Patients also reported that they felt “misled” and that they were not warned about the administrative issues that may arise when seeking reimbursement.
For example, one patient was refused reimbursement because their GP did not ‘sign’ a letter of referral that was emailed to a hospital in Northern Ireland.
This was despite the fact that the letter was sent from the GP’s email address, and the GP had assured the HSE in writing that the referral was genuine.
In another example, a letter of referral from an Irish GP regarding the need for “urgent medical treatment” was addressed to the relevant section of a Northern Ireland hospital and not to a named individual in the hospital.
As a result, the HSE refused to accept a subsequent amended referral letter from the GP.
In another instance, a woman was refused reimbursement because the outpatient consultation with a Polish consultant took place by phone, and not in person, due to Covid-19 restrictions.
The report also noted that a number of older patients who sought refunds for treatment abroad were in receipt of UK pensions and were refused reimbursement as a result.
However, there was no information on the HSE website at the time to warn patients that they may not qualify for the Cross Border Directive scheme if they were in receipt of a pension or benefit from another EU country.
Some older patients had borrowed significant amounts of money to have the treatment but received no reimbursement.
The Ombudsman set out 21 recommendations in the report to improve the administration of the schemes, which the HSE has agreed to implement.
Deering said “their implementation will have a significant positive impact on the lives of those who need to access treatment abroad”.
He added that he was “pleased that both the HSE and the Department of Health have accepted the recommendations made in this report”.
The recommendations includes the need for the HSE to “examine its communications” for those in receipt of pensions outside of Ireland.
The report also deemed that the application forms should be re-designed by the end of this year.
The Ombudsman said this will “ensure that questions with significant impacts, such as the pensions issue, have those impacts highlighted next to the questions, rather than only being explained deep in the terms and conditions where some patients may not become aware of them”.
Another recommendation is for the HSE to put in place a mechanism whereby the source of a referral letter can explain any mistakes contained within it.
The Ombudsman said the HSE “cannot continue to punish patients for errors which are entirely outside of the patient’s control”.
Deering also advised that the HSE should not “refuse applications because referral letters are addressed to a speciality rather than to an individual consultant”.
In a statement to The Journal, a HSE spokesperson welcomed the report and said the health service is “committed to implementing the recommendations”.
“In 2022, the HSE approved 4,809 applications for people living in Ireland to avail of healthcare treatment from another EU/EEA country or the UK with combined cost of €30.9m for reimbursements for CBD and NIPHS and treatments for TAS,” a statement said.
“Since June 2004, when the CBD was transposed into Irish legislation, the HSE has approved 30,781 applications for these schemes at a cost of over €205m.
“One patient may have more than one application and equally one patient may have one application but several episodes of care abroad. As acknowledged in the Ombudsman’s report, in the main these schemes work well.”
The spokesperson continued: “The HSE is committed to making the required changes in the delivery of these schemes as outlined in the report and to provide ongoing assurance that the changes are being implemented to ensure that all applicants to the schemes receive the highest standard of public service that they are entitled to.
“This assurance and commitment was made in person by HSE CEO Bernard Gloster during a recent meeting with Ombudsman Ger Deering to discuss the recommendations in the report.”
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