Patients will be billed directly for all hospital procedures starting Tuesday as Island doctors step up their battle with health care insurers.

Yesterday the public expressed horror at the news and Government said the action would hit the needy the hardest.

Bermuda Medical Society President Dr. Jonathan Murray said doctors would do their best to ensure that the elderly and poor were not hit hard.

Insurers and doctors have been at loggerheads for over a year over a new fee schedule for operations. Dr. Murray said obstetrics and surgery were the sticking points although the two sides were not very far apart.

He said the two specialities made up a tiny proportion of the Island's health care bill, but were very significant to doctors' incomes.

Government attempts to institute a compromise failed in August and now doctors say they have been forced to bill all patients because some doctors have not been paid for more than four months.

Some patients have already been billed in the stand-off since The Health Insurance Association of Bermuda (HIAB) brought in a new coding system on June 1, after a year of stalled talks.

But from Tuesday all hospital patients insured by companies under the umbrella of the HIAB will have 30 days to settle up.

The HIAB includes The Argus Group, BF&M, The British American Insurance Company, Canada Life Assurance Company, Freisenbruch Meyer Insurance Services Ltd. and Government Employees Health Insurance.

HIAB spokesman Gerald Simons said insurers would reimburse at least some of the bill on all claims for medically necessary surgery but, he added "But the issue is how much should be payable."

He said doctors who had been claiming since the HIAB introduced a new fee structure had been paid but others had not put claims in.

"Some doctors have just put them in so we have a whole stack of claims for a summer's worth of work. We, as insurance companies, never stopped paying claims.

"We don't think the practice of billing patients will work. The system we have had for 30 years has worked very well and we would like to keep it."

He said it was the insurers' job to make sure health care was affordable.

Dr. Murray said: "We understand the elderly and disadvantaged might have a problem with finances. As a medical profession I would like to think we can discuss the problem and overcome it."

He said many patients might be covered by their insurance companies who were honouring reimbursement for some operations.

He said: "I hope all will be eventually, but in the present state of confusion it's impossible to predict accurately."

Dr. Murray said they had agreed with the insurers to change to a new coding known as Current Procedural Terminology (CPT) from the old system known as Bermuda Relative Value System (BRVS).

He said: "The Hospitals Act said the cost of any medical act cannot be increased unless the minister signs off on it.

"However the CPT coding is so different from the previous BRVS that you can't relate one to the other, hence it does not come under the strict interpretation of the act.

"The Health Insurance Association of Bermuda instituted this on us unilaterally on June 1.

"We have been trying to discuss it with Government for over a year now and we still don't have any clear vision of what they would like to do.

"We are moving from one system to another and doctors' don't want to drop their incomes, and there does appear to be a substantial decrease in income."

Some estimates have put this decrease at up to 50 percent.

Permanent Health Secretary Dr. Derrick Binns said the normal practice was for insurers and doctor to agree to a fee schedule to be approved by Government.

"I can't say who's wrong or who's right. They have not come up with an agreement."

He said the doctors' proposals could not be accepted by Government although he refused to give details of the sticking point.

Health Minister Nelson Bascome said Government's hands were tied because both the doctors and insurers were independent bodies, although Government was on the verge of getting mediation.

He said: "We are waiting to hear back from the mediators. We expect talks in the next few days."

Dr. Murray said arbitration of the dispute was impossible because there had never been a contract with the insurers.

He said the issue of having outside mediation into talks had not been discussed with members and he said he would surprised if there was anyone on the Island qualified to mediate.

But Dr. Binns said there were a number of people on the Island qualified to arbitrate, or outside experts could be brought in.

Dr. Binns added: "We will do whatever we can to bring them to a resolution. This action will have a significant impact on everybody, particularly those with fixed incomes.

"They have paid for insurance coverage expecting to be reimbursed and now they have to pay and try to get the money back."

Dr. Murray said the insurance companies have said they will agree to cover patients' medical procedures at a restricted CPT level while the doctors want the full CPT coding covering 11,000 different procedures.

Colleague Steven Trott said: "We are not sure why the insurance companies are only willing to cover such a limited number of procedures when they are aware there are additional procedures that patients need to have done today.

"The majority of the Bermuda public has been paying for private medical insurance for years and it doesn't seem right that the insurance companies aren't covering what people require.

"We are very concerned about this. We have received verbal support for a broader CPT schedule from the Ministries of Finance and Health. However the Government has not ratified any fee schedule."

Dr. Murray said: "This is about who steers health care in Bermuda."

And he denied it was a simple power struggle. "It's not necessarily about power. It's about care for the patients.

"The insurance companies can't do it. They are concerned about the bottom line. The Government can't do it. Doctor's should be guiding health care."

Both sides in the row have agreed to sort out future issues in a Government-sponsored Health Care Council due to begin work in April.

Dr. Murray said the current problem rested with Government and doctors were trying to negotiate directly with insurers again with informal talks likely in the near future.

Mr. Simons also said his side was open to talks.