Take these examples:
Surgeon A is an ENT consultant surgeon.
He performs an E1910 on two different patients. He bills both patient’s insurance company £1,600 each. No problem except Patient ONE’s insurance company fee structure is £1,600 for an E1910 but Patient TWO’s insurance company fee structure is £1,945 for the same E1910 episode.
Surgeon A has therefore by invoicing Patient TWO’s insurance company £1,600 i.e. the fee he gets from Patient ONE’s insurance company undercharged by £345 or 20%
Surgeon B is a gynaecologist and has the same issue.
He performs a Q0800 on two different patients who are insured by separate insurance companies. He invoices both insurance companies at £636 each. Save Patient ONE’s insurance company’s fee structure is £636 whereas Patient TWO’s insurance company’s fee structure is £800. Surgeon B, by using the fee structure for Patient ONE only, has undercharged by £164
Both carry on billing not realising that the fee depends on whom the patient is insured.
Different private medical insurance companies publish different fees for the same surgical procedure.
To illustrate we checked four different medical insurance companies this afternoon in order to confirm the fees for an E1910.
The fee was £636, £676, £775 and £800.
We then turned to Surgeon B and the medical code of Q0800 and found the fees were, dependant on which of the four medical insurance companies we checked, £636, £676, £775 and £800 respectively.
Is there a lesson in all this?
There certainly is. Don’t set fees at the level published by a single insurance company.
Check which fee is paid by which insurance company for the same procedure i.e. don’t assume they are the same. They may not be.
A published medical fee for the consultant surgeon can and does alter not only between private medical insurance companies but can also alter over time.
In every single case, it’s always worth checking the fee structure paid by the patient’s insurance company and not assuming it is the same across all private medical insurance companies.
Invoice for two different codes in the same surgical episode incorrectly and it is easy to get into even more trouble. For example Insurance Company X may allow 100% of the higher value code and 50% of the second but Insurance company Y may allow 100% of the first but only 33% of the second. Imagine what happens if all episodes are billed at 100% and 33%. Immediately you’ve lost 17% of your second fee!