One of the most common mistakes made by a private consultant surgeon when invoicing is undercharging for their work. This is alarming when considered against the question most asked by a private consultant surgeon.
This always spins off into a debate concerning how private medical insurance companies are the enemy. Fees are always being reduced with the private surgeon being paid less and less it is claimed. That may be true sometimes but is not the right place to start.
The right place to start is to make sure the private consultant surgeon is charging the correct fee. Such fee may be less than the surgeon wants of course but, many times, be more than he thought he was entitled to.
Take the example of an orthopaedic surgeon who contacted MHM to process her medical invoices recently. She was of the opinion her consultation fees were too low. That also may be correct. But that was the consultation fee the insurance company was prepared to pay.
In reality, the orthopaedic surgeon was unaware some of the insurance companies were prepared to pay a fee for minor procedures carried out at a consultation. They would pay a procedure fee together with a fee for the consultation. Whilst some insurance companies weren’t prepared to pay both fees, some were. Instead, the consultant had been charging ONLY for the minor procedure. She had not been charging for a consultation as well.
The same situation was equally applicable to a private dermatologist just as it was applicable to a GI surgeon. It is not therefore applicable solely to orthopedic surgeons. It is applicable to many specialisms. The issue, therefore, becomes one of: am I charging the right fee?
To confirm the fee is correct a review of procedure codes and the fee for the procedure code should be undertaken. Both may then be compared against the fee structure of the private medical insurance company concerned. Each code and combination of codes must be checked against the fee schedule of the private medical insurance company. The often stated assumption that all insurance companies pay the same fee for the same procedure code should be rejected.
Take the example of a repair of the primary repair of the Achilles tendon. Insurance company A pay a fee of £336 whereas insurance company B pay £405 – £69 more! The orthopaedic surgeon concerned was of the belief insurance companies paid out the same fee. She had UNDERCHARGED by £69 as a result.
To return to the original issue of charging a consultation fee alongside a fee for a minor procedure, take a look at injection into soft tissue. The same insurance company paid a fee of £108. The orthopaedic surgeon in question was unaware that a follow-up consultation could be charged in addition to the fee for the injection. Another £150 on top of the £108! Thus the correct charge was not £108. It was in fact £258
To further illustrate the point a dermatologist may charge the very same insurance company, £91 for curettage of skin or lesion. He or she may also charge a follow-up consultation fee in addition. If the follow-up consultation fee is £100 (and it is for the MHM client concerned) the fee for the WHOLE event has doubled!
Thus the most common mistake in medical invoicing is not realising that fees can and do differ between insurance companies and also that some, not all but some, private medical insurance companies will actually and quite happily pay MORE for your work than you may be aware of.
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It is depressing the number of times I hear potential clients rubbishing insurance companies.
In my experience the reasons normally cited are incorrect. Far from it.
I’ve lost track how often I’ve been told an insurance company won’t pay for something.
Yet when I ask if the insurance company have actually been asked IF they will accept a charge, the answer comes back that they have not.
I have all the private medical insurance companies on speed dial.
They need to be as I speak to most of them every single day of the week. There are many, many things I’m already aware of.
There are also some things that I don’t know or more importantly, that may have CHANGED.
I ask them all sorts. For example – I ask them to confirm a patient’s policy number.
I ask them to confirm why an invoice has only been partially paid.
Sometimes I ask them if I can or cannot charge for a certain medical episode. Which brings me neatly to the W9040 code.
I was invoicing for an orthopedic consultant surgeon recently. His specialism was knees and during a follow-up consultation, he administered a W9040. This particular CCSD code represents an injection into a joint or soft tissue.
The question arose if I could charge a particular insurance company for a follow-up consultation fee AND a fee for the injection.
So I called them.
The answer came back yes I could. I could charge £120 for the consultation and £50 for the injection i.e. £170.
The insurance company would happily pay such an invoice.
Compare and contrast that with work I was performing for a dermatologist recently.
This time the question arose of an S5210 (an Injection into subcutaneous tissue). I’ve only recently started invoicing for this client and thus it was important to establish what could and could not be charged for.
More specifically, would the insurance company accept an invoice for the follow-up consultation AND the injection? Yes, they would.
£125 for the consultation and £108 for the injection i.e. £233.
Remember however that I had asked ONE specific insurance company.
When I asked others the same question, some would NOT allow the separate charge.
What was concerning was previously the dermatologist had not been charging for the S5210 at all.
I actually asked his practice manager why this was so.
The answer came back that the question had been asked of an insurance company before and the answer was no.
The problem was that whilst that insurance company concerned did not (and still don’t) allow a charge, other insurance companies DID allow a separate charge.
But nobody had asked the other companies.
Instead, it was assumed the decision covered ALL insurance companies.
Thus on numerous occasions, insurance companies are wrongly blamed for their actions.
It was only by speaking with the individual insurance companies that I identified which ones would accept the charge and which ones would NOT accept the charge.
Insurance companies are NOT the enemy.
If you call them, you may be surprised at what you are told.
That is not to say you will always obtain a positive response but more times than not you may.
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A pre-authorisation can be backdated.
In by far the majority of cases, your patient will obtain authorisation in advance of the actual date. But sometimes, the patient arrives and hasn’t obtained a pre-authorisation. First question: should you see the patient?
Of course, you should; patient care must come first.
But what do you do? It does happen, it shouldn’t but in the real world, it does. How should the private surgeon handle it then? Ask the patient to ring his/her insurance company and obtain the pre-authorisation. But….
If say the consultation was on the 8th and the patient does not call the insurance company until the 15th, the patient should make sure the insurance company knows when it took place. In this example, the patient did not tell the insurance company it was a week earlier. When MHM tried to invoice, it was declined as the consultation was before the date upon which the pre-authorisation was issued.
If the patient holds an insurance policy, which will not allow the backdating of a pre-authorisation you’ll have even more difficulties. In which case an invoice for the initial consultation should be sent to your patient.
This is not the insurance companies being unreasonable.
If you think about it, the patient has incurred liability on behalf of the insurance company. But the insurance company knows nothing about. Ultimately the patient is liable for the consultation fee of course thus the invoice is sent to the patient. The patient rings up (normally quite upset).
They point out they are insured and are indeed covered for consultations in their view.
Numerous phone calls between the patient and the insurance company and the issue gets sorted. The invoice is submitted to the insurance company and its paid in full. This time it was anyway.
It would have been paid a lot quicker IF the patient had been asked to advise their insurance company the consultation was for a specific date. When the patient arrives for the consultation it is then simply a matter of confirming with the patient, the correct authorisation numbers have been obtained.
If this is happening to you, it’s an issue that should be addressed and prevented otherwise you may spend 15 – 30 mins just sorting this one small problem out!
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Two different MHM clients – both consultant surgeons – have been advised by a specific insurance company that the fees are being reduced. They are not amused, to say the least. But what can they do about it? Nothing.
Actually, that’s not strictly true. In a perfect world, there is much they can do. But we don’t live in a perfect world. We live in this one.
In a perfect world they can, for example, pass any reduction in fees on to their patients. Save of course their recognition agreement with the insurance company forbids them to do so. If they do they are at risk of de-recognition. Ah came the reply, the insurance company won’t find out. Yes, they will.
Or they can stop seeing patients referred to them by that specific insurance company. In both cases during the last half of 2016 that is over £10,000 worth of referrals. Both would suffer double percentage digit drops in private practice turnover. That is not good.
Both of these consultants, however, are by no means stupid. Neither of them just react. An immediate reaction is potentially the worst thing to do. Indeed many years ago MHM worked with one consultant who did just that when denied a fee by an insurance company. He even went so far as to tell the insurance company concerned unless they immediately put his fees back up he would forgo his recognition with them and refuse to see their insured patients. They didn’t so he did. And immediately saw a 23% drop in the private practice turnover. Do NOT react. What is required is a considered response of all the options.
In the case of the MHM clients, I calculated what the drop-in fees would mean over a six month period against an assumption that the lack of referrals would lead to 25%, 50% or a 100% drop in patients from that specific insurance company. In all cases, for obvious reasons, there was a loss. But at least that loss was now quantified.
That said a refusal to see patients from the specific insurance company concerned due to fee reduction would automatically lead to a 100% drop in surgical fees as clearly if a consultant does not see a patient, it is extremely unlikely he’ll take that patient into theatre.
Sadly there are only two options in reality: accept the reduction or don’t accept the reduction. I’m afraid the insurance company really are in the driving seat when it comes to setting their fees and there is little a private consultant surgeon can do about it. Many years ago a private consultant surgeon could charge what they liked and to a certain extent with a self-funding patient, they still can. However, with insured patients, those days are long gone. Rightly or wrongly, those days are over.
So what should the private consultant surgeon do?
MHM suggests an analysis of how the reduction will impact on the private practice should be undertaken. That will at least quantify how the reduction will impact on the private consultant surgeon in actual financial terms. All the data will be contained on a sales ledger and with the aid of an excel spreadsheet, it’s relatively easy to perform the analysis.
Such an analysis also confirms how the reduction will impact on MHM for MHM charges a percentage of what is actually paid to the consultant. If that figure is lower then the MHM fee will also be lower. In other words, the pain is shared. Thus I don’t like it any more than the private consultant surgeon but I can’t do a lot about it either.
The bottom line remains accept the fee reduction or reject the fee reduction. That I’m afraid is the reality.
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A question, which was asked recently at a private practice seminar MHM were presenting at.
Interestingly the question was asked by a consultant surgeon who had started his/her private practice two years earlier. He was of the opinion that such excess was the responsibility of the patient’s insurance company who would collect excess or shortfall amounts from the patient on his behalf.
Sadly this is absolutely NOT the case at all.
The responsibility for the collection of such items rests very squarely on the consultant himself.
Consider excess and the cause of excess?
When the patient obtains private medical insurance there will be an amount – or excess – agreed on the policy.
The exact amount of the excess will depend on how much the patient pays for his/her policy. Generally speaking the higher the premium, the lower the excess.
It’s just like car insurance, if you agree a £500 excess, the premium will be lower than if you only agree £100. That’s fine – until you come to make a claim on your insurance. Private medical insurance carries the same principles.
So, when the patient comes to see you and you claim the cost of your services off their insurance company there could well be excess for which the patient is liable. The consultant is responsible for the collection. Not the patient’s insurance company.
The consultant who asked the question called a few days later because to this horror, he had in excess of £5,000 worth of uncollected excess in the previous two years unpaid and due to him which nobody was collecting.
The supplementary issue, however, is why were the excess amounts allowed to build up over two years without anybody noticing?
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Earlier this year another of the major insurance companies are no longer accepting paper invoices.
For a number of years now, MHM has argued paper invoices should be avoided. We have instead taken advantage of the offering by the majority of medical insurance companies. We submit invoices for medical services electronically. It has saved a fortune in postage costs regardless of invoices being posted out in one large envelope per insurance company every week.
Never mind that we don’t have to post invoices out five times a week instead – with five times the cost of a weekly posting either.
They are produced much quicker and cheaper than in paper form.
The amazing thing is that some private medical insurance companies still allow paper invoices to be sent to them.
Invoices for self-funding patients should always be mailed to a patient. It is bewildering however that consideration should still be given to sending a paper invoice to an insurance company. Regardless of whether the insurance company allows it or not.
MHM supports those insurance companies who insist as part of them granting recognition that invoices to them are electronic only.
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Medical coding is vital.
Without the correct code the chances of getting paid decrease.
It is unlikely if you wish to invoice electronically you will be able to invoice without a code anyway.
Insurance companies use medical coding to identify and detail a procedure. For example, an Orthopaedic surgeon will understand precisely what a Multiple arthroscopic operation on the knee is.
But that’s a lot to put on an invoice. Plus there may be variations on the episode.
Instead, use the code W8500. That will specifically identify the surgery you have done.
If you are planning to invoice electronically you won’t be able to input the whole description anyway.
So where do you find the code?
CCSD codes can be located on the CCSD website.
The Clinical Coding and Schedule Development Group (CCSD) consists of the five major healthcare insurers – Aviva, AXA-PPP, BUPA, Simply Health and Vitality Health.
Its main purpose is to maintain a common standard of procedure codes. Such codes reflect current medical practice within the private healthcare sector. They are published as the CCSD Schedule of codes.
The various insurance companies will, therefore, recognise the majority of codes.
However, a word of caution.
Whilst the example above of W8500 will be recognised, a CCSD code does not come with a suggested fee rate.
The fee rate for each code is up to the individual insurance company concerned. To find the correct fee for the code, you will need to check with that insurance company.
For example, the W8500 mentioned earlier carries a fee of £615 for one insurance company. For a different insurance company, the fee may be £550. If you charge £550 instead of £615 by mistake, you will NOT have your fee increased.
If however, you charge £615 when it should be £550, your fee will be reduced.
Whilst not so important for consultations, a CCSD code is imperative IF a surgical episode is required. The patient must quote the code to his or her insurance company when pre-authorisation is being requested.
When an invoice is sent to the insurance company, the code should appear on the invoice, This will reconcile to that expected by the insurance company.
If alternatively, you do NOT use CCSD codes payment will be substantially delayed if made at all!
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Private medical practice is a business must be run as a business.
A surprisingly large number are NOT run as a business which is fine provided you don’t expect to make any money or making money is not the aim of the practice.
If the aim, however, IS to make money, then put in very simple terms:
That means, making sure all the administrative functions that are mandatory to running a successful business are in place, working AND regularly monitored.
All too often when I meet potential new clients there are signs that none of the above are considered when starting.
Indeed there are some clients who have never considered the above to be part of the equation.
Take the marketing of the practice as an example: where are the patients going to come from? How will they find the consultant? What will attract the patient to that particular practice?
On many, many occasions this has not been thought through.
Instead sometimes – not always but sometimes – there is an expectation that patients will just “find” the practice.
In reality, seldom will a patient do so.
Instead, the practice must market itself.
The basis of such a glaring omission is most likely rooted in the career of the consultant prior to setting up his or her private practice.
All MHM clients have established themselves very securely in the NHS and obviously in the NHS, the patients are – sometimes literally – delivered to the consultant.
This most definitely is NOT the same in the private sector when the patients must be attracted.
The other common and glaring omission is a consideration as to actually charging the patient or their insurance company for a consultant’s work.
If you are going to build a successful private medical practice you must run it as a business.
Doesn’t mean at the expense of the patients. Far from it in fact.
But you must remember your practice is first and foremost a business.
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At a medical conference recently a friend of mine was discussing the future of the private practice industry and what lay ahead.
My colleague shared the view that the “younger” newly appointed consultant is more adaptable to the direction of change in the private practice.
Thus they were a major driver in how the industry moves forward.
I say they are entrepreneurs.
Let me explain why.
Certainly newly appointed consultants cannot look forward to a hefty NHS pension at the end of their career.
The younger consultants are also facing a squeeze in fees from private medical insurance companies. Not to mention they journeyed through a number of years to reach the position they are in now.
Yet they find themselves in an increasingly competitive market.
The market is more competitive than those who came before them. The younger consultants are, so the evidence suggests, much more open to a business orientated approach than before. They have to.
In other words, the newly qualified consultant still has a mortgage to pay, mouths to feed, etc so is much more receptive to being an entrepreneur.
Say what you may but the fact remains the private medical healthcare environment is changing. Just as the NHS healthcare environment is changing.
At the forefront of such changes will be the newly qualified consultant surgeon. To adopt or take advantage of such opportunities as may arise, the new qualified are using technology as never before. For example, they are much more amenable to the use of internet-based technology for marketing and PR. They have to be entrepreneurial.
To prosper, let alone survive, they must invest in technology. What is interesting is that they are more willing to do so than ever before.
To succeed with a private practice requires a significant amount of seriously hard work. This is not to suggest the application of medical skills is not important. It is.
But what is equally important are entrepreneurial skills. Marketing, financial expertise, and business managerial skills for example. These should not be assumed to be easy. They now have to be acquired.
Consider that a consultant – newly qualified or otherwise – works within the NHS.
The NHS provides a support infrastructure including premises, secretarial support and, crucially, a constant supply of new patients.
In the private sector, none of these items will be supplied. The consultant has to go out and actively find them for himself.
And that is why the consultant surgeon should be viewed as an entrepreneur.
Does anyone have a different view? I’d be delighted to hear from you.
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It is common in my world to be presented with a number of unpaid invoices. The remit is to go get paid for them. That I can do.
If they were raised in the first place that is.
If they have NOT been raised it is much more difficult.
I’ve done it many times. It’s not without its difficulties though.
Self-funding patients normally express amazement that they haven’t been invoiced.
More than a few have put forward the view they thought they would have been invoiced ages ago.
Some have even said they’ve called the consultant surgeon’s secretary to ask where the invoice was and still nothing has arrived.
There is a very simple remedy to this problem.
Send the invoice.
What is much more problematic is the same issue with a private medical insurance company.
This is especially true where, as part of the consultant’s recognition criteria, the insurance company insist all invoices are submitted within 6 months of the episode date.
It matters not one jot whether the episode was surgical or a consultation.
The invoice must be submitted within 6 months of the date.
This is precisely the situation I faced late last year when reviewing the billing process of a northeast based ENT surgeon.
She had just over £4,250 worth of invoices for a single insurance company that had NOT been invoiced.
They were all way over six months old.
Worse still they added up to just over £4,250.
The wrong solution to this is to ask the insurance – politely or forcefully – to accept the invoices even though they are so “old”.
Most likely the private medical insurance company won’t agree to even look at them.
It is irrelevant to blame the insurance company.
A complete waste of time.
The correct solution is to consider HOW this situation had been allowed to happen.
In other words, be much more concerned there is not another £4,250 worth of surgical episode or consultation that hasn’t been invoiced. Hopefully, the value will be less but you need to check.
In most cases, there will be uninvoiced outpatient appointments. Sometimes entire surgical procedures have not been invoiced. In all cases, you need to find out.
You should also make sure a robust process is in place to prevent this from happening again. How?
The simplest of daily or weekly routines. The sanity check.
Using one of my current clients as an example, I know he holds two outpatient clinics per week and is in theatre once a week.
Therefore I should see two clinic lists and a theatre list every week.
If I don’t, I call his secretary.
Sometimes, I’ve only received one clinic list because there was only one clinic. Other times though, there were TWO clinics but she has forgotten to send me the 2nd clinic list.
Sometimes he hasn’t returned the clinic list.
The important point is that we know about it and make sure the discrepancy is sorted.
A very simple sanity check will prevent a build-up of uninvoiced appointments or surgical episodes. But do not think this is a “should” check.
hen each week, ALL MHM client’s get a spreadsheet. ONE document. All they have to do is check, the clinics have been invoiced. Surgical episodes are on there too.
This is very much a “MUST” check.
If you don’t, it is so easy to end up with £4,250 worth or surgical episodes or outpatient appointments that you can charge for but will almost certainly be refused for payment by the insurance company.
Then you may have to contact your patient and explain due to your own poor administration the patient must settle your bill.
I have no issue doing this even for we are where we are. I have to say in most cases the patient is not at all impressed!
It’s so much easier not to put yourself in the position in the first place by performing a sanity check each week.
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This is a topic that comes up frequently when I meet Private Consultant Surgeons.
Indeed, the point was touched upon last year in a blog regarding asking self-funding patients to pay in advance.
Self-funding patients represent the major risk of non-payment for the private consultant.
That said MHM does not advocate requesting full payment before a consultation.
One group of Private Consultant Surgeons made it mandatory for ALL self-funding patients to pay in advance.
Within 3 months they had lost over 90% of their self-funding patients. This represented a value several times LARGER than the balance due from unpaid self-funding consultations.
Cancellations are completely different from “Did Not Attend” and frankly none of my guys (and gals) suffer from a significant number of cancellations. Yes, there is a small number but it is not a problem.
It is more an inconvenience.
But there is another aspect to the debate. That aspect is those patients who ‘Do Not Attend” i.e. are defined as DNA
Patients who do not attend for their consultation represent a 100% loss. It matters little if the consultation is 20, 30 or 45 minutes. If the patient does not attend the consultation then that time is lost for no revenue may be charged for it. Certainly, this is true if the patient is insured. It is extremely unlikely any insurance company will allow a fee to be charged if the patient did not attend for a consultation.
The issue, however, is different if the patient is self-funding.
Of course, it is possible for the consultant to send an invoice to the patient who did not attend.
That does not mean, however, the invoice will be paid.
The conclusions are therefore as follows:
if the patient is insured there is very little the consultant can do about DNA patients
if the patient is self-funding however taking a deposit (which can be deducted from the final charge) has the effect of REDUCING the number of “Did Not Attend” patients.
Would such an approach have a negative impact on the reputation of the consultant?
I suspect it would.
It would be interesting to hear from anyone who has a different approach and the results they have obtained. Feel free to email me at:
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There was a story on the BBC website regarding the safe use of mobile phones when driving.
Apparently, there are still those who hold the phone to their ears. There are those who read emails and text too.
It’s all to do, or so it’s claimed, with the concept of working over and above that which is normally required.
Maybe I’m the exception to the rule as I have a wonderful and 100% safe way of using a phone whilst driving.
It all goes back to a Friday afternoon on the M25 last year when I was happily talking away on my Bluetooth kit to a friend of mine.
And totally failed to realise I’d just driven past the junction for the M40. Since then I’ve had the phone switched off.
No more beeps as an email arrives and no more distractions.
But I hear you say, I could possibly miss an important call?
Yes, I could.
For at least two hours i.e. in between motorway service stations anyway.
Will the world end in those 2 hours?
Modern technology is great.
You can be in constant communication with anyone, anywhere in the world.
I have clients who email me at obscure times of the day. As consultant surgeons, they don’t exactly work 9-5 hours. I email them at odd times too.
But seldom does an email require an immediate response either from them or to them.
Of course, it requires a response at some point but it does not require a knee-jerk reaction. Most likely the best thing to do is not respond immediately anyway. Much better to understand the issue and then give a measured and fully considered answer for the client’s benefit.
Much better for my clients and much better for my business.
My clients are the single most important thing in my business. They require total commitment and a consistently high level of service.
Just the same as any business.
Yet this concept of working over and above normal requirements to satisfy a client persists. I
’m not against working really long hours. I’m absolutely not against providing an extremely high level of service. I do it.
My clients provide an incredibly high level of care to their patients i.e. they do it too.
What I am against is this notion that working really long hours and answering the phone or emails proves dedication to a task.
I suggest in reality, long hours may prove counterproductive sometimes or in the case of using a phone/answering emails, etc whilst driving proves there is always an accident just waiting to happen or a motorway junction to miss.
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Taking ONE real-life client as an example.
Week ending Friday, January 25th: out of 15 consultations, 4 (four) came back with excess/shortfall deductions totaling £575. So for a total of £2,500 worth of revenue from outpatient consultations £575 or 23% came back short. Looking back to the same week in 2018, the number of shortfalls/excess was roughly half this.
The question as to why this is happening is not the concern. The concern is what are you going to do about it. If 23% continues the downside and potential loss to the consultant is significant. There is only one real way to resolve this issue. Phone them!
Sure you can write letters and even email but nothing gets a response like a ringing telephone. Most patients are unaware of the issue but some think this is an issue between them and their insurance company. In other words, the patient thinks they need to pay the insurance company. They think the consultant gets paid in full by the insurance company. There are variations on this but the crucial point for the consultant is not to establish why; its to ensure he recovers the shortfall/excess efficiently.
But if telephoning the patient is the most efficient way to tackle the issue, it does not automatically follow its the easiest. It has to be done professionally and with due diligence. The long-suffering med-sec really won’t have the time to do this as professional and caring as she undoubtedly is. I promise you faithfully, she won’t want to phone patients for money and will be thinking this is the least enjoyable part of her job.
There is an alternative though: do nothing. Some patients actually will pay but this assumes they a) are aware of the shortfall/excess and b) make it good straight away.
What if they don’t?
Assume it’s not £575 or 23% a week or £27.6k a year (£575 multiplied by 48 – not 52 weeks as you will have 4 weeks off a year). Assume instead its 10% for 24 weeks (i.e. roughly half of the current numbers) and allows for some patients paying without being contacted.
The potential losses for the consultant, in this case, reduce to £13,800 per annum. That’s a chunk of change in anybody’s book still.
What’s significant is that at a number of client meetings recently I’ve asked what the client considered the biggest threat to the practice during 2019.
Most popular was a further reduction in private insurance fees. That may indeed turn out to be a big problem.
But at this point, empirical evidence suggests its potentially leaving the back door wide open so to speak and enduring £13,800 worth of potential losses right off the bottom line.
I’d be really interested to hear from anyone who is seeing an increase in shortfalls etc and their views on remedies.
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Ever thought what is the most often quoted reason for non-payment by a patient of the excess?
The same reason is quoted over and over again.
It is not ‘I haven’t got the money” nor is it “I didn’t realise it was so much”, not even “The invoice must have got lost in the post”.
Actually, it is…
“But when I registered at the Private Hospital, they took a swipe of my debit (or credit] card and the fees should have been taken from that”
Why is this always being quoted?
Why should you be suspicious?
In answer to the first question, it’s because the patient assumes the bill will be “sorted” by the hospital.
They don’t realise that the transaction is between them and you.
In answer to the second part, you should not be suspicious.
This is not to suggest the fault lies with the reception staff at the private hospital.
Recently I went with my own partner to a private hospital and as she checked in, it was very clearly explained that her debit card swipe covered only the hospital fees.
There was even a sign up to that effect on the wall in front of us. So my partner, as all private patients, should realise what is covered by the swipe of their debit card.
Yet a few weeks’ later when the invoice arrived from the consultant, she said something was wrong The Hospital had taken a swipe of her card when she attended the consultation.
Quite rightly, she called the consultant’s secretary who explained the situation and payment was made the same day.
It does demonstrate, however, the most often quoted reason why payment for an excess invoice has not been made.
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If fees differ between insurance companies how can they be checked and monitored?
For example, a fee for a fictitious CCSD code XY4321 can differ between the big five insurance companies by as much as £100. Add to the equation another code. AB9876.
It may or may not be performed at the same time as the XY4321 dependent of the insurance company concerned.
Then the problem may become complicated.
AB9876 has 5 different fees anyway PLUS some insurance companies allow 50% of the AB9876 fee when invoicing alongside XY4321. Others, however, only allow 25% and the remainder don’t let AB9876 be invoiced alongside XY4321 at all!
Take a moment to realise why this is very important. It’s because if there is an error in the calculation, the chances are the consultant will UNDERCHARGE.
So how do you track and monitor the situation?
The solution is to create a grid that details all the codes you perform – most consultants do a relatively few different types of a surgical episode – and program the grid to calculate the correct fee for each code and the correct fee for each individual insurance company combination.
This is exactly what MHM does for all its clients by way of the “MHM Grid” and thus very, very rarely does MHM over (or more importantly) undercharge for anything.
Even more interesting is MHM don’t actually charge for building and maintaining a “Grid”. Clients get it free.
Do not, however, think, once programmed the Grid will always be correct.
The other factor is that fees and their combinations will and do alter over time.
For example, if you check fees with BUPA you’ll discover the fees are correct up to October 24th at which point they may (but not necessarily will) change!
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Following on from a recent blog and questions raised at a presentation to consultant surgeons, I was asked to further explain why you must invoice quickly.
The obvious one is that the sooner you invoice, the sooner you get paid. Fairly straight forward you may think. Yet many consultants in my view take far, far too long to invoice – delays of up to 2 weeks are not unusual.
However, have you ever considered what might happen if there is benefits limit on a patient’s policy?
You won’t even know if there is or not and certainly you don’t know what the limit is. But if the limit is reached either partially or in full before you’ve submitted your invoice you are pretty certain to be shortfalled.
It is almost like whoever asks first gets paid first and whoever asks last gets paid IF there is enough money left. So if you invoice for your work a few weeks after the event and more importantly after everyone else, you run the risk of increasing the number and value of the shortfalls you are subject to.
For example, MHM was recently asked to review the invoice process of a consultant surgeon.
In doing so, the cash flow of the consultant was compared to that of an existing MHM client.
The consultant had many, many shortfalls and excess amounts on his accounts. The MHM client had less than 12.
Why? Same specialism, similar volumes of work.
However, MHM invoiced for the original client within 48 hours of receiving his clinic/theatre list. The consultant was raising invoices at the end of each month. Coincidence. No.
That is why it’s important to invoice quickly. If you are not, what can you do about it?
If you wish MHM to benchmark against what it should be, email me.
And it’s free!
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A couple of examples recently where consultants who have tried to base their fees on the best rate available. Take the consultant who realises that PMI company Num 1 pay £300 for a procedure whereas PMI company 2 pay £400. He decrees he will charge PMI Company 1 the PMI Company 2 rate.
Great idea. Right up to the point PMI company 1 receives the invoice for the higher amount. They will decline to pay that fee. Most likely they will shortfall it. But, replies the Consultant, no problem. The patient is ultimately liable for any shortfall. I know of one consultant who even puts on his website “we use PMI Company 2 rates to calculate our fees and therefore there may be a shortfall which you will have to pay”
Yes, the patient is liable for a shortfall BUT not when the consultant is fee assured he isn’t.
Most likely a letter addressed to the Consultant will arrive sooner or later from PMI Company 1 pointing out that such “inappropriate billing” is not acceptable; carry on doing it and recognition is at risk.
It’s incredibly similar to unbundling. Continue doing it over a number of months and for sure eyebrows will be raised. Even if there is no “fee assured” status PMI Company 1 will be well aware of regular and consistent charges that are in excess of their published fee schedule.
Notwithstanding the above, of course, consultants want the best possible fee for a procedure but attempting to obtain the same by “inappropriate billing” is not the smartest way to go about it.
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The patient arrives for the consultation. He hasn’t obtained a pre-authorisation from his/her insurance company.
Yes, of course, you should; patient care must come first.
But the patient does not have a pre-authorisation! It does happen, it shouldn’t but in the real world, it does.
How should this be handled then? Ask patient to ring his/her insurance company and obtain the pre-authorisation a soon as they possibly can.
If say the consultation was on October 28th and the patient calls the insurance company on October 30th, the patient should make sure the insurance company know when the consultation took place.
In this example, the patient did not tell the insurance company it was two days earlier. When MHM tried to invoice, it was declined as the consultation was before the date upon which the pre-authorisation was issued.
If the patient holds an insurance policy, which will not allow the backdating of a pre-authorisation you’ll have even more difficulties.
This is not the insurance companies being unreasonable.
The patient has incurred a liability on behalf of the insurance company, which the insurance company knows nothing about.
Ultimately the patient is liable for the consultation fee of course so an invoice is sent to the patient.
The patient rings up (normally quite upset) and points out they are insured and are covered for consultations in their view.
Numerous phone calls between the patient, the insurance company later, the issue is finally resolved.
The invoice is submitted to the insurance company and its paid in full.
It would have been paid a lot quicker and without the hassle IF the patient had been asked by the consultant to advise their insurance company the consultation was for a specific date.
If this is happening to you, it’s an issue you can address and prevent otherwise you may spend 15 – 30 mins just sorting this out!!
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To successfully perform medical invoicing or medical billing there has to be a degree of focus on the task itself.
In fact, there has to be a total concentration on the expected outcome. But what is the outcome
The outcome is always the same.
Getting an invoice paid.
The total focus must be applied to this outcome.
Making sure the private consultant surgeon is paid is the task and therefore total focus must be on that. The problem arises when the total focus is not possible.
For example: in the middle of invoicing for 12 consultations and 4 medical episodes the telephone rings.
More often than that, however, is an email alert pinging up! Worse still the person responsible for medical billing decides, as they don’t really enjoy doing that specific task, to do something else.
A major distraction from focus is other people’s demands.
MHM once had a client who called 8 times within 35 minutes.
He afterward complained his medical billing wasn’t being done speedily enough.
It didn’t take a genius to work out that the 8 phone calls were a total distraction from raising the very invoices he expected to be raised.
It doesn’t really matter what the distraction is even though with modern technology advancing so much over the years, the likelihood of distractions has increased ten-fold.
For example, I may be in the middle of a task and my mobile pings to say an email has arrived.
A phone may also ping because a text has arrived.
The opportunity for distraction(s) is enormous. Yet these distractions can remove focus from the planned outcome.
They can stop processing an invoice correctly, resolving an issue that is preventing an invoice getting paid or they can even stop an invoice being raised in the first place.
Modern technology is great.
It enables MHM to communicate with its clients speedily and efficiently.
Clients can provide data to MHM equally efficiently. It also enables MHM to raise invoices electronically and deliver them at the push of a button.
But it can also be a blessing in disguise if MHM were to let it distract from the job in hand.
Thus it is worth repeating that the planned out is for the private medical professional to get paid.
That is what MHM is there for; nothing else.
If the technology on occasion stops that, then remove the technology for a while.
This may sound revolutionary but in the real world, ignoring technology when the technology actually prevents achieving the planned outcome is not as silly as it sounds.
For example: when I’m raising medical invoices for a client – every single morning invoices are processed at MHM – I switch my email off.
Thus there are no distractions caused by emails arriving.
Before anyone raises the question of an email being important, may I suggest that in reality whilst emails may be important seldom are they time critical? They are normally requests for data or asking a question.
All three examples are important but they are not, despite what people may claim, time critical.
My favourite example of this is the person who was tasked with locating new premises for MHM.
She emailed me one-morning last year but when I didn’t immediately respond, telephoned to confirm if I had received her email.
This despite the instruction to email details to me and being advised I would respond later that week.
As she couldn’t even follow that instruction, she immediately lost the opportunity of finding new offices!
The world will not end and a private medical practice won’t immediately collapse if an email, a phone call or even a text are not immediately responded to.
That is not to say a patient inquiry should not be immediately answered.
In the case of a patient calling then absolutely they should. Have someone designated to answer the phone.
It looks awful if a patient calls and the phone isn’t answered.
But don’t have the same person responsible for medical billing AT THE SAME TIME for if you do the phone calls and/emails will provide the distraction to caused the planned outcome to be missed.
Medical billing is not the easiest thing to do in the world.
It requires concentration and attention to detail.
If the outcome is expected to be prompt payment of an invoice for medical services, the focus should be directed to just that. You know what happens if I switch my email off during the morning or I have the text alert set to silent? Nothing.
Except I raise numerous invoices for clients, resolve issues with insurance companies and make sure MHM clients are paid.
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Sometimes even a consultant surgeon does not understand how valuable his time is.
All of my guys are incredibly busy.
I’m amazed at the volume of work they get through in a single day.
They are either on-call, doing a ward round or in theatre. Then they have to see their private patients. That explains why most of them call me either very early in the morning or in the evening.
It doesn’t bother me.
It’s my job to fit in around them and make their life easier.
Recently however I was asked to review the private practice of a consultant who was having serious difficulties generating any cash into his practice.
And following my question to his long-suffering medical secretary, it didn’t take long to establish why.
The question was: what is the biggest problem you have this week. The reply said it all:
“I never get a response to the queries or receive the information I need after I’ve asked Mr. Surgeon. He always seems too busy to deal with the things I need”
The situation was despite leaving messages on his phone or emailing him, seldom did Mr. Surgeon respond. He was too busy. Yet most of the information the med-secretary needed was fundamental to generating cash into the practice. For example, two clinic lists a week ago (result: no invoices sent out) or remittances from an insurance company (no idea who had or hadn’t paid) or the post Mr. Surgeon picked up and put in his bag one-day last week (it had cheques from patients in it)
So I sat down with Mr. Surgeon and asked him what he thought about it. His response was a classic: “I just don’t have time to deal with all that. My private patients are paying to see me so they must come first”
I agree with him.
Sadly therein lies the cause of the issue.
The reason Mr. Surgeon is having difficulty generating the cash is due to him not dealing with such issues as the missing clinic lists or not passing over remittance advices.
Mr. Surgeon needed to make very sure, the support facilities of the practice were dealt with. The word “support” suggests these things can be demoted to a “Too busy to deal with that and they are not that important so I’ll deal with it later” category.
Sadly they can’t.
Eventually, they catch up with you. In the case of Mr. Surgeon, they were the reason he was struggling to generate cash into his practice.
Mr. Surgeon is a very safe pair of hands and the patients love him. He’s a nice guy too. But he needed to change ONE SINGLE THING in the way he works. He needed to put aside an hour a week to make sure he’s covered all his administration too.
So he did.
And within a month Mr. Surgeon was pleased to see not only more cash coming into his business but that he wasn’t being chased by his med-sec so often.
In case you are wondering why I don’t have such issues with MHM clients its because every single week my clients take their post or clinic lists etc scan them to me and promptly proceed to forget about them afterward.
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