In terms of medical billing, this perhaps is one of the statements I hear from private consultant surgeons more frequently than others.
The following example illustrates that despite the rejection of the fee how the fee was established confirms there is little the consultant can do about it.
The consultant surgeon concerned had applied to be recognised by private medical insurance. MHM had spoken to the consultant and pointed out fees should be confirmed when recognition was being arranged. The consultant was well qualified, had held a substantial NHS post for a number of years and his/her specialism was in high demand. The private medical insurance company was keen to offer recognition. Thus recognition was granted.
Yet despite the warning by MHM fees had not been checked.
MHM was subsequently asked to handle the medical billing side. In order to do so, we need to know how much consultation fees were. The medical professional, however, did not know what the consultation fees were. Thus alarm bells immediately started ringing.
Consultation fees would have agreed to and would have been detailed in the pack supplied to them by the insurance company concerned as we had advised. So we called the insurance company and quoted the newly acquired provider number.
As usual, the insurance company was keen to point put the consultant had agreed to adhere to the published fees.
It is always amusing when “fair and reasonable” is quoted to me because it depends on what the consultant thinks is “fair and reasonable”. More specifically what happens if the thinking differs between the two parties concerned. And that is precisely what happened in this example.
The insurance company deemed that £130 was a fair and reasonable fee for a consultation.
The medical professional deemed that £175 was a fair and reasonable fee.
And thus the consultant instructed MHM to charge consultation at £175.
MHM pointed out that it would indeed charge £175 as instructed. All that would happen, however, is the insurance company would reduce the value of the invoice down to the £130 originally agreed.
And that is precisely what did happen.
Despite the medical professional objecting strongly to a consultation fee of £100 and insisting a “fair and reasonable” fee was £175, the invoices were reduced in value.
It mattered little to the insurance company that the MHM client had colleagues who were both charging and getting paid £175.
Even before I asked the question I knew this was to be true. It mattered even less to the insurance company that a second colleague was paid even more than £175. This was so because the second colleague was in a completely different specialism!
Sadly the MHM client had based their practice business plan on a consultation fee of £175. They had done so because they had asked colleagues how much they were paid. Then they had assumed such fees would equally apply to them.
MHM, per normal, had no issue calling the insurance company concerned and arguing the case on behalf of the medical professional.
That said it was an argument that it was never going to be won. The simple reason remained that at the point of recognition the MHM client had accepted the fees.
Sure enough, the insurance company stood firmly behind its agreement with the consultant.
ASSUMPTION LEADS TO PROBLEMS.
The moral of this sorry tale is best summed up by the above heading. I’m not suggesting you shouldn’t challenge fees for consultations or indeed a surgical episode but don’t put yourself on the back foot by accepting fees and then challenging them afterward.
As painful as it is for the MHM client, it really is as simple as that.
Check your fees before you agree to them!