Couple of examples recently where consultants have tried to base their fees on the best rate available.
Take the consultant who realises that Medical insurance company Num 1 pay £300 for a procedure. Medical Insurance Company Num 2 however pays £400.
He therefore decrees he will charge Company 1 the higher Company 2 rate each time he performs that procedure.
Great idea. Right up to the point Insurance Company 1 – who the patient is actually insured with – receives the invoice for the higher amount.
As a result, Insurance Company 1 decline to pay that fee and most likely will shortfall it. But, replies the Consultant, no problem because the patient is ultimately liable for any shortfall. Thus he invoices the difference to the patient.
I know of one consultant who has on his website “we use Medical Insurance Company XXX rates to calculate our fees. If there is a shortfall you will have to pay”
The patient may be liable for a shortfall BUT not when the consultant is fee assured he isn’t.
If the consultant is fee assured he has undertaken to charge in line with the specific insurance companies fee schedule. Most likely a letter addressed to the Consultant will arrive pointing out that such “inappropriate billing” is not acceptable.
Inappropriate medical billing is 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.
Carry on doing it and the number of referrals to the consultant by the insurance company will reduce. Ultimate the consultant’s recognition with the insurance company is at risk.
Not withstanding the above, of course consultants want the best possible fee for a procedure but attempting to obtain a higher fee by “inappropriate billing” is not the smartest way to go about it.
pete@medicalhealthcaremanagement.co.uk
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