This issue came up recently with a consultant surgeon.
How are benefits and fees accounted for against a patient’s package?
Consider the total benefits payable under a patient’s policy. For example, the benefits payable is £100.
It could be more. The fees mentioned below could be higher too.
Against such a benefits package, fees are deducted thus:
£20 is paid out. The total benefits figure reduces to £80.
Subsequently, the patient requires surgery. £50.
This is also paid.
The accumulator reduces to £30.
Finally the hospital tenders their account: £20. The gasman submits his: £10. The benefits accumulator, therefore, reduces to ZERO.
The benefits package is equal to the fees.
If the initial is £21, the surgery £51, the hospital £21, and the gasman £16 then the total fees = £109. Against a total benefits package of £100.
Thus, if fees exceed the total benefits a shortfall will be created.
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Recently I spoke about the clarity of data. You need to be able to read it.
Consequently, I took a phone call last afternoon from an MHM client. He reminded me how I once gently pointed out texting me was not a good idea.
We laugh about it now but back in 2018 when we started working together it was painful.
For example: if there was a problem with the clinic list I’d phone him and leave a message for him to call back.
Generally speaking this lead to a text message asking what the problem was.
So I’d text back.
This lead on to a mammoth text change that could easily take an hour. An hour of interruptions and an inability to sort a single problem out because it wasn’t clear what the issue was.
Nor was it clear what the suggested solution was.
This would happen most days to our mutual annoyance.
To be honest, I could not afford to spend so much wasted time that way. And neither could the client.
So we stopped.
Now if there is a problem, I text and ask him to call. He texts back giving me a time and I call him at that time.
Consequently on a bad week we speak once. On a terrible week, we speak twice. But we seldom have those sorts of weeks anymore.
Indeed today was the first time I’ve spoken to him since early July.
And that is why it is vital to get the right data, in the right format and prevent the very opportunity for issues to arise.
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I called one of my friends early one evening last week. His phone went straight to voice mail. Curiously he didn’t call me back with half an hour or so per normal. He called me this morning instead. He explained why. Every Wednesday, he and his wife have a “date night” They switch their respective phones off.
No emails, text or phones interrupting them. They spend time talking to each other.
And that got me thinking.
A couple of years ago I started doing something similar. At the end of each day, I’d put my phone on silent and switched my emails off too. Why?
Because each day I need time to review any opportunities/problems I’ve got to deal with the next day. It also means I can think about an issue at length, leave it overnight ready to be re-thought about on the next day. That stops me making knee jerk reactions and allows time to have a fully considered opinion ready. Rarely will you get an immediate reaction from me. My response to an issue has, therefore, been thought through.
Yet many medical practice managers or indeed consultant surgeons running a practice, don’t stop and think through an issue. They are too busy. But alternatively, they are too busy because they don’t stop and think through the issue.
Sadly I see this all too often when I go meet a potential new client. Many of the issues they are facing have their source in a previous decision. The previous decision itself could well be based on a decision before that one even. One of those decisions in the chain was almost certainly not thought through.
For example: recently I blogged about a group of gynecologists in the West Midlands who, in an effort to stop issues with self-funding patients decided ALL self-funding patients must pay in advance.
Immediately the problem with self-funding patients stopped. Because there weren’t any self-funding patients anymore.
This was a solution to the problem. It worked. Sadly, however, it had some unpleasant side effects i.e. no patients.
Clearly, they hadn’t thought through the consequences of their decision. They had reacted. Yet the reaction caused another problem i.e. no more self-funding patients. That was unfortunate as 23% of their practice was derived from self-funding patients.
The above example is indicative of the cause of many of the issues within that particular practice. It was relatively easy to put the self-funding issue right because I’ve faced that specific challenge a few hundred times previously (email me for how). Getting the practice manager and the three consultants to change their mindset though was much more difficult.
They did change though because they had seen a 100% reduction in self-funder outstanding invoices. Sadly this was at the expense of a 100% reduction in self-funder patients.
They changed not just because I knew the answer. They changed because they realised when I faced that issue previously, I’d allowed myself sufficient time to give it serious thought and consideration before reaching a decision. I implemented a course of action that didn’t put patients off by asking payment in advance but did reduce the number of outstanding self-funder invoices. As a bonus, it stopped the problem with self-funding patients who were DNA too!
And that is why it is important to put the time aside and think through an issue before deciding on a specific course of action.
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Most MHM clients have reported issues with self-funders when we get involved. It is also the source of many calls made to MHM.
With the self-funding market increasing, it is important to understand the reasons self-funders can be a problem.
But what, based on empirical evidence, are the three most common reasons a self-funder hasn’t paid:
The first issue is always the same. When the patient is contacted as a self-funder, he/she claims never to have received an invoice.
Whilst this is obviously easy to rectify, how many medical professionals are 100% certain the invoice was sent in the first place?
Obviously some self-funders will be naughty so to speak but generally, they will pay if sent an invoice.
So the first common reason – the self-funder hasn’t been invoiced.
The second issue concerns the use of debit or credit cards. In 99.9% of cases when a patient arrives at a private hospital he/she will be asked to provide a swipe of their card.
Sadly on numerous occasions, the patient is unaware the card only covers the hospital fees. It does NOT cover the consultant’s fee.
The MHM solution is when the patient first makes contact with the consultant, he/she is advised the card swipe will NOT cover the consultant’s fee.
This should be followed up by a note on the consultant’s invoice stating: This invoice is NOT covered by any debit/credit card details you may have provided to the hospital.
The second common reason – the patient thinks they have already paid
The third issue is the easiest of all to resolve. Frequently, a self-funding patient has called upon receipt of the consultant’s invoice to say they are insured.
This must be addressed immediately. Invoicing the wrong person is absolute insanity.
The cause is a failure at the patient’s initial point of registration to ensure the correct details are taken.
The third common reason – there is a major failure in the consultant’s registration process.
If the above three items are correctly managed and a firm process put into place to manage the minority of self-funders who don’t pay, the number of outstanding self-funding invoices drops in most cases by over 80%
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Sometimes, getting more patients isn’t always the right answer.
The right answer is to get paid for the ones you have already seen.
Over the last three months MHM has been working very closely with an ENT consultant. His sole aim is to see more and more patients.
That way, he will make more money and retrieve the dire financial situation he has found himself in.
Thus he has reduced his consultation time down from 30 to 20 minutes. Therefore he’ll see one more patient each hour.
But the cause of his financial problem is not he doesn’t have enough patients.
He is owed a considerable amount of money. He is not getting paid.
Seeing more patients and not getting paid for them, will not help!
He needs to get paid for the ones he has seen as well as the new patients.
A simple cause.
Invoices aren’t being raised after each clinic. Instead, they are being raised every Saturday morning when “it’s quiet”.
But the problem with that is not all invoices are being raised.
Many of the patient details are incorrect. But his secretary can’t correct the details because many of the insurance companies she needs to speak to to get the right aren’t open on a Saturday.
Or if she needs to speak to a patient, she may or may not be able to reach them by telephone.
The very first thing to do is to make sure the details ARE correct. That is much easier than it sounds.
Then, she needs to invoice every single day.
In doing so she will identify issues quickly. Then she must resolve those issues the very same day.
It’s only by doing so will the dire financial situation the ENT has found himself in will get resolved.
Seeing more patients but not being able to charge for them, won’t resolve his problem.
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This blog could easily have been called ‘YOU WON’T UPLIFT A FEE BY DOING THAT”
Recently a private consultant – the colleague of a current client in fact – called me with a problem.
Sadly it was a problem very much of their own making!
In an effort to increase fees, the consultant had decided that a surgical episode should be billed as follows: AB1234 £640 and CD2468 £75. So the total fee = £715.00 and on March 1st, 2021 the insurance company was sent an invoice for £715.0.
And promptly proceeded to reject it.
The fee for the AB1234 was and still is correct.
But with this particular insurance company offering 50% of a second code, the CD2468 fee was wrong to start with. It should not have been £75. It should have been £37.50. Great. Save the invoice would still have been rejected.
Why this time?
If the private consultant had checked they would have discovered that this second CD2468 code was deemed by the insurance company to be part and parcel of the AB1234 procedure.
Thus it was never going to get paid anyway and it was deemed unbundling to submit an invoice and charge for both items.
Skip forward to July,2021. The consultant – or more accurately his long-suffering secretary – has called, emailed and written to the insurance company because the consultant is still unpaid the £640 for the AB1234.
Hence the phone call to MHM.
For once even I couldn’t do anything about the multi-code element.
It very clearly states on the insurance company website that a consultant cannot invoice a CD2468 alongside an AB1234.
In fact, it also says so on the CCSD website.
It is deemed unbundling to do so.
MHM called the insurance company and has confirmed the original invoice has now been canceled and re-submitted an invoice for an AB1234 £640.00. It is being paid too.
Moral of the story?
You will NOT make more money by unbundling.
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At a recent on-line presentation, I was asked about the costs and use of accounting software. Bearing in mind the presentation was to consultants who had not yet established a private practice, numerous eyebrows were raised when I answered…
You may not need it yet.
This does not mean accounting software is unnecessary. Some private practices do need a software package and there are some fine software packages out there. They are cost efficient too. MHM works, very successfully, with many of them too.
But for those seeing say 10 or 12 patients a week use MS Excel or Apple Numbers and an online diary. MHM has clients for whom it raises invoices on Excel and uses the same to run a sales/debtors ledger.
The sales ledger – once password protected – can be sent either to the client and/or the client’s accountant.
If a private practice is a business – and it is – then you MUST keep an eye on all costs.
It’s always useful to ask yourself the question: am I paying for something I don’t actually need?
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They are not just for tax reasons. They are not just to keep the accountant happy. There is a time-critical reason too.
Remittance advice will confirm the values that have been paid. It is a mistake to assume that the invoice will be paid completely. It may not be.
For example and taking one remittance received by an MHM client.
Of the ten invoices paid, four of them were subject to excess deductions.
This is why remittances should be checked. And before they are stored for tax reasons or to keep your accountant happy.
In the above example, each invoice detailed on the remittance was reconciled against a debtors ledger. Only then was the payment recorded. It was then the number of deductions was identified. In this example, the total came to some £350.
The next step is to identify why the deductions have been made.
Whilst all four deductions were correct and were in respect of excess amounts it is surprisingly common for a deduction to have been made in error.
In the recent past, one MHM client had an invoice for surgery deducted in full because the patient’s policy had expired. At least according to the patient’s insurance company it had expired. It had done so after the date of the surgery. In this case, at the date of the surgery, the policy was “live”
Consequently, the insurance company was wrong to decline the invoice for payment.
A call to the insurance company concerned quickly identified and confirmed the insurance company was in error. The invoice was immediately cleared for payment. Insurance companies do make mistakes. Not many thankfully but they do happen.
If the deduction is correct then immediate action should be taken to contact the patient and a request made for payment – by the patient – made.
So the number and reasons why deductions have been made by a private medical insurance company can easily be identified and subsequently actioned on behalf of the consultant surgeon.
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Working for consultant surgeons is fun.
However, since one particular private medical insurance company decided to outsource their help desk or their “advisors” late last year, there has been a marked reduction in their level of customer service from it.
Considering the people calling them are either consultant surgeons or calling on behalf of a consultant surgeon, that is pretty bad.
Indeed the average time on hold for this particular insurance company, for example, is now well over 10 minutes.
That’s pretty awful considering it used to be less than a minute.
What is ironic however is that now I have a choice of music to listen to.
For example: would I like to listen to classical music, pop music, jazz or rock music? I decided on classical as it happens and am currently listening to Bach. I like Bach.
But it has got me thinking…
Isn’t being given the option of what to listen to missing the point entirely?
This is an even worse option than being told my “call is important to us” and then the call is unanswered.
Shouldn’t the aim be to answer the phone call rather than offering a choice of music to listen to?
All private consultant surgeons sooner or later will need to speak to an insurance company.
Whether this is at the point they are attempting to gain recognition or to check a fee is correct is not relevant.
Sooner or later – particularly if you are billing an insurance company – you have no choice but to speak to them.
But is it absolutely necessary to call?
That is my favourite question to ask.
The first port of call so to speak is always to consider if an action is necessary. In other words, what is causing that action to be necessary and can anything be done to prevent the necessity of the action?
In the case of speaking to a medical insurance company, in theory, many of the calls should not be necessary.
If an invoice is raised and submitted correctly for example then payment should – again in theory – just flow through. Reducing the necessity of speaking to an insurance company is always a good aim.
It is the very reason I check remittance advice sent by an insurance company most carefully.
They record many of the details as to why an invoice, for example, hasn’t been paid either in full or partially.
For example: if a partial payment has been made the reason why will be detailed on the remittance advice.
Thus the number of calls required to a private medical insurance company will be reduced.
Nonetheless, the fact remains there will ALWAYS be an occasion to call an insurance company. It may be, for example, that the fee has been reduced and you don’t know why.
The point is there may be genuine reasons why it IS necessary to speak to an insurance company.
Contrast this however with another insurance company I’ve spoken to this morning. I called them and was told I was on hold, was caller number 3 and the estimated hold time was 4 minutes.
Fine; I can live with that.
It is up to me whether I’m prepared to wait in line or call back.
Having formally complained to the medical insurance company in the first example that their customer service is not good four times so far, I did consider WHY they had outsourced?
It would appear the reason is financial. It’s cheaper.
It was once said by an extremely wealthy man that price is what you pay and value is what you get. I agree wholeheartedly.
Cheaper isn’t always the best.
And time is money too.
I’ve actually written this blog whilst being on hold and listening to Bach. So I’ve used the time to do other things too. What would happen, however, if I was a private consultant surgeon with an already overworked medical secretary who had letters to type or worse still was on hold so patients couldn’t ring her?
That would reflect badly on my practice.
I’m all in favour of outsourcing.
I would say that though because my business is intrinsically the provider of an outsourced facility to private consultant surgeons.
Even so, I get seriously frustrated at being told either my call is important – well answer it then – or I’m offered a choice of music to listen to.
I don’t actually want either to hear either.
I want my issue resolved quickly and efficiently.
Cheaper and slower shouldn’t be an option.
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If you get the basics right many problems with getting paid aren’t allowed to happen.
As a result, accidents aren’t allowed to happen.
The basics are as follows:
Patient’s full name
Their full address including their postcode
The Patient’s date of birth
Policy number of insurance company.
A pre-authorisation number issued by the insurance company
Correct CCSD code
But it doesn’t stop there.
Your name and address
Your provider number
A unique invoice number
Date of the treatment/consultation
But if you don’t get all 14 on your invoices you make it harder for the insurance company to pay you.
Where do you get the above data from?
If you are practicing from a private hospital almost certainly the above will be recorded on the hospital’s registration form.
If you are invoicing electronically, its pretty much standard that you MUST have the above data immediately to hand anyway.
The same is also true if you are dealing with a self-funding patient or you endure having to collect a shortfall/excess amount from a patient.
In other words, the chances are you are going to need all 14 pieces of data. Therefore it makes more sense to get them right the first time.
But the proof of the pudding is very much in the eating. Have a guess at what are the TWO major reasons an insurance company does NOT pay your invoice?
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An MHM client held one of his twice-weekly outpatient clinics recently. Nine patients; so there should be NINE invoices.
Except there are only EIGHT?
A quick look at the list indicates one of the patients is designated as inclusive care; no invoice required. But hang on a second, an invoice was raised for a surgical episode recently for this very patient and sent to an insurance company for payment. Indeed it’s been passed for the payment already.
How can the follow up be deemed inclusive care if the surgical episode was chargeable to an insurance company? Generally speaking, it can’t.
Simple explanation. The patient had been incorrectly designated as inclusive care for this clinic. Once the error is corrected, there are NINE invoices. Happy days. After all its only one episode
Make that mistake only once a week for a single month and you potentially lose over £500.
And that is why MHM checks the clinic list is right each time and every time.
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How can I charge more for my work?
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 were 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 orthopaedic 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 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 a 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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A shortened version of a recent conversation with a well established private consultant surgeon.
Very recently one of the major PMI players announced a further reduction in payable fees.
The immediate retort from another very well established MHM client was to pass any reduction on to the patient.
That’s all well and good but not if she is fee assured with the insurance company concerned.
If a fee reduction is passed on to a patient by a fee assured consultant, the consultants’ recognition may be put at risk.
None of the above means MHM agrees with insurance companies reducing fees – even though market forces may on occasion be the root cause of such reduction.
By all means, argue with the insurance company.
And I already am.
But don’t assume the argument fees should not be reduced will be successful.
There again it might not.
Instead, make sure you are charging the very maximum you can.
Make sure you are charging for everything you do.
If the surgery takes twice as long as expected, request an uplift fee. If a double consultation is required, charge for a double consultation.
It’s not as difficult as you may think it is.
And don’t forget to do a sanity check each month.
If you think a 20% reduction in fees is bad, consider the 100% reduction if you fail to charge an entire consultation.
Whilst the question of where fees will go will be considered in future blogs, its important before even thinking about your fees to make absolutely sure you are charging the right fee already.
You’d be surprised how many aren’t!!!!
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I’m a really, really impatient person. I like everything done yesterday.
Which is why I go incredibly slowly to start with.
When I begin to raise invoices for a consultant surgeon, for example, I’ll check I have the right provider number. I’ll check all the online systems and EDI protocol are 100% accurate. Is the consultant’s address correct?. I’ll check the insurance company has the right BACS payment details.
What I’m actually doing is reducing down to absolute zero as many reasons as I can possibly think of that will prevent the invoice being raised correctly.
What happens if I don’t take this approach?
Invoices come flying back. They don’t come back straight away of course.
It may take weeks before I’m notified there is a problem. Then I have to work out why it went wrong, get all the details to put the error right, actually put it right and then resubmit the invoice.
Then I have to wait again for the invoice to be reprocessed. Eventually, the invoice gets paid.
One absolutely true example. Recently MHM project managed a group of three surgeons in the Midlands. All three were seriously considering closing the practice as they were not making any money. They were not getting paid as they should.
The senior of the three was responsible for invoicing for all three each week.
Just under 50% of the invoices he produced came back unpaid. The insurance companies concerned requested more details or raised query against them.
The senior consultant complained he hadn’t got enough time to keep sorting these things out. He had to raise invoices as quickly as possible. He tended to view any medical invoicing problem from the “quickest fix” point of view. To use his words “I only want to be a surgeon and not a whatever-you-call-it”
My kind of guy. Don’t talk about it. Get on with it. Play to your strengths. Save that is precisely what he was not doing.
He jokingly told me his blood pressure was sky high due to the constant stream of invoice problems.
Yet it was this “quickest fix” approach that was the cause of his blood pressure. Many times his quick fix in one area (get them on the phone or treat the patient as a self-funder for example) caused a problem in another area. Then he had to fix that.
This was leading to a six /seven-week delay before invoices were accepted by insurance companies on top of the agreed payment terms.
It took me two months to re-map the process, test, amend it and bed it in. In month three we started to see the results. Invoice failure rate had dropped from roughly half to below 6%. Cash flow had doubled. The time with which the three consultants got paid decreased from around every 75 days to about 50.
All three consultants were happy. Imagine the surprise though when I told them that wasn’t good enough?
I thought we should see at least a 98% acceptance rate and to be paid every 30 days. And I wanted to achieve that as of yesterday starting with raising the invoices every single day rather than weekly. The invoice process was robust. There were very few errors. There were few reasons why we shouldn’t be paid.
Told you I was impatient.
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A Scottish colleague called me last week. A case of “can I pick your brains for two minutes?”
I’m always happy to take such calls for many times I have called others with precisely the same request. My colleague was confused as to what could or could not be charged alongside a consultation fee. Specifically, the consultant surgeon she worked for was administering injections at a consultation and she thought she could not charge a consultation fee AND a fee for the injection. She thought this would be a clear case of unbundling.
Except she was wrong.
Her consultant was perfectly entitled to charge a separate fee for the injection.
A quick analysis of the outpatient consultations where my colleague had NOT charged since January 2021 revealed she had UNDERCHARGED by a total of £837 so far this year. She had however and quite rightly charged for every single consultation – failure to do otherwise is the fastest way to lose the private consultant’s money – but had shown on her invoice the fee for the appointment alongside a ZERO fee for the injection. In the case of one single insurance company she had failed to charge in respect of 9 separate patients £450 worth of injections (9 @ £50 each)
The bottom line is that if she undercharged injections by £837 in the first 6 months of 2015, should she continue throughout 2021 she would lose her consultant £1,674 for the entire year.
How did I know the answer to this one? MHM has clients in the same specialism as my colleague’s consultant. Also, MHM checks fees every 90 days with all insurance companies for the rules of what can and cannot be charged, what is bundled and what is deemed unbundled change. Plus, most importantly, applicable fees alter!
How many of you check what the correct fee is? Not just when you set the practice up but on a regular basis?
But I can’t help but wonder how many consultants undercharge – are you one of them but don’t realise it?
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At a on-line 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 adapt 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.
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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One of the major areas MHM is approached about is excess and shortfalls.
In July 2021, empirical evidence indicated 26% of all claims to private medical insurance companies are subject to an excess/shortfall. This is not to imply the insurance companies are to blame.
The reality is that patients have reduced the costs of their premiums over the last few years by agreeing to a higher excess.
But the knock-on effect of this has been an increase in excess deductions.
So what can the private consultant surgeon do about it?
The number one rule in tacking the issue of excess deductions is to identify when they happen. This is actually easy. The remittance from the insurance company WILL confirm when an excess has been made. It most likely will also state their insured (the patient) has been notified.
But under no circumstances should the problem be left at that.
The practice must, at the very least, action all shortfalls straightaway. Under no circumstances should this be allowed to exceed 7 days. Excess or shortfall deductions made again MHM clients are actioned within 48 hours. Such action may be an invoice for the amount of the excess/shortfall immediately sent to the patient. The invoice must state how much is due, why and how it should be paid.
This must be followed by a very robust process that makes sure such invoices are followed up.
If you want a complimentary PFD of the invoice MHM uses for excess or shortfalls, email me at the address below:
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This is a topic that comes up frequently when I meet Private Consultant Surgeons.
Indeed, the point was mentioned 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 payment in advance.
One group of Private Consultant Surgeons once made it mandatory that ALL self-funding patients paid 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 in no way is it a problem.
It is more an inconvenience.
But there is another aspect to the debate.
That aspect is those patients who ‘Do Not Attend”
Patients who do not attend for their consultation represent a 100% loss.
It matters little how long the consultation is.
If the patient does not attend the consultation then that time is lost and no revenue may be charged for it.
Certainly, this is true if the patient is insured for it is extremely unlikely any insurance company will allow a fee to be charged if the patient did not attend for a consultation even if a cancellation was necessary for genuine reasons.
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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Most consultants when they first start a private practice, consider how best they can set their fees. In reality, it is not the consultant who sets his or her own fees. It is the patient’s insurance company.
Consideration of fee setting should be viewed from two distinct areas:
1: Consultation fees 2: Surgical Fees
Consultation fees first.
Consultation fees (for both initial and follow up) will be agreed at the point of recognition by the respective insurance companies.
Clearly, if you have 20 years experience and are one of the few consultants within your geographic area, then you may be able to command a higher fee.
In reality, most likely you not be in such a position. You will be offered consultation fees at a level set by the insurance company you are dealing with. In return, the insurance company will refer patients to you.
In the case of self-funders, however, there is nothing to stop you charging any consultation fee you like. Save of course if there are other consultants in your area then their fees will influence that which you charge.
Surgical fees, if anything, are the easier one to deal with.
The insurance company with whom your patient is insured will always set surgical fees. You may feel the fee is too low and therefore charge more. Almost certainly your invoice WILL be rejected. Keep sending invoices in for fees greater than that allowed by a particular insurance company and you run the risk of being de-recognized.
Whether it is right or wrong for insurance companies to hold such power over the setting of surgical fees is for another article. I have very firm views on it but at this point, the stark reality is that the insurance companies do hold such power.
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Take, for example, a patient who requires an injection which may be performed by a private orthopaedic surgeon at an outpatient consultation.
Thus you raise an invoice for, as an example, £185 [£90 for the consultation and £95 for the injection]. Please be aware for the purposes of this article the values are fictitious!
Upon receipt of the invoice by the patient’s insurance company, the value is rejected; as you CAN’T charge both for a consultation and an injection on the same invoice on the same day. You can charge for one or the other but not both. So you are paid £90 for the injection only. What is interesting is that the immediate reaction from some consultants could well be to charge just for the injection and argue that is the right thing to do.
That said, it has already been suggested that the alternative would be to have the patient attend an outpatient consultation on, for example, March 10th and then attend for the injection on March 25th. See the patient twice in other words. In such a case, the consultant CAN charge for both.
Not sure that’s in the patient’s best interests though but if the aim is to max revenue it is certainly in the best interests of the consultant. I’m certainly not saying its right or wrong. I am saying it’s an option.
Where it gets really tricky, is that some insurance companies WILL let you charge for a consultation and an injection at the same time. Others will let you charge for some injections at a consultation but not all injections. Some, as mentioned, will not allow a charge for consultation and injection regardless if they happen at the same event.
And don’t forget not only do different insurance providers pay different rates for consultations; they also pay different rates for the injection too.
Gets a whole lot worse when the injection is pre-authorised as the fee for a consultation is higher than that for the injection, the orthopaedic surgeon charges for the consultation only yet the insurance company is expecting an invoice for the injection.
Unless you check each consultation and injection episode with the insurance company concerned, you will be! More likely you will actually undercharge at some point in time. For example: if the insurance company DOES allow a fee for consultation and injection if you charge only for one sooner or later?
You’ll be out of pocket.
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