In terms of medical billing or medical invoicing that perhaps is one of the statements I hear from private consultant surgeons more frequently than others.
The following example however really illustrates that despite the rejection of the fee, examination of how the fee was established confirms there is very little the consultant can do about it.
Applied for recognition
The consultant surgeon concerned only recently applied to be recognised by the private medical insurance. That in itself is not too difficult a process. MHM spoke to the consultant and pointed out fees should be checked extremely carefully when recognition was being arranged. The consultant was extremely well qualified, had held a substantial NHS post for a number of years and his/her specialism was in relatively high demand. The private medical insurance policy was keen to offer recognition and refer patients to the consultant also. The recognition was thus granted.
Yet despite the warning by MHM fees were not checked.
MHM were subsequently asked to handle the medical billing side of the consultant’s practice. In order to do so we need to know how much the outpatient consultation fees were for even we can’t charge if we don’t know how much to charge. The medical professional did not however know what the consultation fees were and the alarm bells immediately started ringing.
Fees incidentally that they 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 usually, the insurance company were keen to point put the consultant had agreed to adhere to the published fees.
Fair and Reasonable
It is always amusing me when “fair and reasonable” is quoted to me because it depends on what the consultant thinks is “fair and reasonable” against what the insurance company think 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. More specifically how it defined a “fair and reasonable” consultation fee.
The insurance company deemed that £100 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 a consultation at £175.
MHM pointed out that it would indeed charge £175 as instructed HOWEVER all that would happen is the insurance company would reduce the value of the invoice down to the £100 that had been originally agreed.
And that is precisely what happened. 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.
Don’t start the battle
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 was true because the colleague concerned had many, many years more experience. It mattered even less to the insurance company that a second colleague was paid even more than £175 for a consultation. 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 and 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 (a battle if you will) that was never going to be won. The simple reason remained that at the point of recognition the MHM client had accepted the fees. It mattered little the client hadn’t fully understood what was being offered (despite the fees being detailed in the recognition pack sent to the client).
Sure enough the insurance company stood firm 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 so to speak by accepting fees and then challenging them afterwards. As painful as it is for the MHM client, it really is as simple as that.
Check your fees before you agree to them!
pete@medicalhealthcaremanagement.co.uk
by 
Leave a Reply