There a few things I hear that automatically set alarm bells ringing when I look at the invoicing and billing process of a business.
“I’ll take a look at it next week”
“I’ll get round to it in a bit”
“I’ve been meaning to look at that”
The final of those items was said to me recently at a medical conference in London.
I was sitting on a panel facing an audience of medical professionals who wanted to ask what made a medical practice successful.
In amongst the various questions was one relating to how to monitor the medical billing of a medical practice.
To me the answer is simple. Before you can measure any part of a business, you must establish a standard to measure against. Which is what I said to the questioner. I asked if he knew how many invoices he had raised last month and the total value he had invoiced. Sadly he didn’t know either.
But, I continued, to improve the performance of your practice you must make sure you know how you are performing against whatever standard you decide is the most appropriate.
Now consider the issue of invoicing with a real MHM example. One of my guys – a private consultant surgeon – saw 25 patients between Monday, November 5th and Friday, November 9th. Therefore I should be able to see 25 invoices.
That is a simple but effective control which makes sure everything is invoiced. The standard has been set because one invoice is required for each patient.
If I only have 23 invoices I have a problem!
But it also means at the end of November I can add up the number of invoices and also tell the client how many patients he has seen during November. Then we can compare that number with the number the previous year and see if it is higher or lower.
The introduction of such a basic management control isn’t a nicety. It is an absolute necessity if you are going to manage the invoicing process or indeed the whole business effectively.
The audience member agreed fully but then the alarm bells went off when he said “I’ve been meaning to look at that for a while now” He hadn’t because there always seemed to be some other problem to deal with.
That tells me his management controls aren’t as robust as they should be. It also tells me he is suffering from one of the worst and easily avoidable causes of business failures out there:
Leads to a backlog of invoices because it diverts you from identifying a backlog is building up.
Is even worse than having no cash because it distracts you from raising the invoices and thereby getting paid.
Procrastination is the cause of the problem he has because various insurance companies have declined his invoices for treatment as the consultation was more than 6 months ago.
Set time aside every single week to make sure, you DO invoice and to make sure you review what is happening with YOUR money!
pete@medicalhealthcaremanagement.co.uk
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The normal item when I get asked to review a consultant’s invoicing process is the potential for weakness in the area of records on his/her part.
Sometimes, I’m presented with a carrier bag full of invoices, remittances, and receipts. My favourite though remains the cardboard box stuffed full of pieces of paper. That was the filing system. Close examination of the pieces of paper in the cardboard box suggested they were invoices. Many in fact did not have an invoice number on them. Indeed the majority did not actually have the word INVOICE printed on them either.
That can be a problem when I come to reconcile payments against such payments IF they’ve been paid at all. That is important because it’s difficult to contact an insurance company and discuss invoices for one individual patient if the invoice does not show a specific invoice number. In fact, the only way you can tell them apart is if the values are different and they are on different dates.
It’s always best to have a unique reference number on an invoice i.e. an invoice number and a date. And don’t forget to print the word INVOICE on it. At least that way, you stand a chance of knowing which ones have or have not been paid.
Then the hard part starts as you begin to look at what is or is not on the invoice and get a feel for what was likely to be paid anyway and what was likely to be rejected due to total lack of detail. Normally this is followed by a request to see clinic lists and the process of obtaining the right data off the clinic list for submission to the insurance company.
There is also an additional cost to not keeping accurate records. When it comes to tax time, its going to take a lot longer – and thereby cost much more – for your accountant to do the necessary computations. At worse you could end up paying too much tax.
All because records aren’t kept correctly. Please keep accurate records if only because it means you stand a much higher chance of being paid!
Please email me if you want details of the bare minimum records you should be keeping for invoicing purposes.
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I argue with medical insurance companies all the time.
Let me, however, be very specific about when and why I argue with them. I argue with them when I think they are wrong or when I think they have made a mistake.
A real example will illustrate why and when to argue with an insurance company.
MHM has a client who performs a specific test at a consultation with a patient. He has done so on more than one occasion obviously and with patients holding cover provided by all the major insurance companies, I’ve invoiced for him many, many times. Per normal MHM won’t reveal who the client is, his specialism or indeed the true value of his charges. For the purposes of this example please assume the charge is £125 for the consultation and £75 for the test.
The invoice was raised and sent electronically to the insurance company. It detailed all the correct details i.e. patient’s name, complete address, date of birth, policy number, pre-authorisation number. The correct CCSD code for both the consultation and the test were used. It also indicated the correct price for each and a total value for the combination involved. In other words xxxx (the consultation) = £125. The yyyy (test) = £75. Total value = £200.
Surprisingly, when the remittance arrived electronically from the insurance, only the consultation had been paid. A note appeared on the remittance advice stating it was not possible to charge for a consultation and that particular test at the same time.
Except, you can.
Before picking the phone up to call the insurance company concerned I first visited the insurance company’s website. The codes were correct. The fees for each code were correct. There was no indication that the combination could not be charged alongside each other whatsoever. I was pretty certain even before I’d checked that I was right but it doesn’t hurt to check. I could have been wrong. More likely it could have been that the rules had been changed.
Establishing the facts is vital when raising invoices for medical billing. Actually its true of all commercial situations but is dependant on what is deemed to be a fact. What some claim to be facts turn out to be anything but sometimes. In this case, though the facts were as I thought them to be. It was perfectly acceptable to charge the two codes together. Only then did I call the insurance company.
Having passed the normal Data Protection requirements i..e patient identifiers etc, I asked WHY this particular charge had been reduced? It was explained to me that the combination was invalid. It was unbundled as they say. Except I insist it was valid, was not unbundled and further, the insurance companies OWN website said the combination was permissible. The phone went quiet for a while and then I was told the insurance company was wrong and I was right. The £75 would immediately be paid to the consultant involved.
Despite what you may think it is not unusual for an insurance company to make a mistake, admit they have made a mistake and then rectify it straight away.
Don’t, however, call an insurance company and twist the facts. By that I mean don’t call them and say their fee isn’t right and should be much higher. That is not a fact, it is an opinion. When faced with a combination of codes that can’t be charged together do NOT separate them into two invoices one being sent on a Monday and one on a Tuesday. Don’t unbundle in other words. Insurance companies may make mistakes but they aren’t stupid.
Its very much a case of “picking your arguments” and challenging an insurance company in the right way and on the right subject.
But is also very, very much a case of noticing that the insurance company have made a mistake and asking them to rectify it. The number one statement made to me by private consultant surgeons is that fees are too low (I agree for what its worth) and that insurance companies are really, really difficult to deal with. They are not.
As regards fees, however, if you want to increase your fees the first port of call is actually to check you have a) charged the right amount to begin with and then b) making sure you ARE ACTUALLY PAID the right amount. In the example above the £75 wasn’t lost, it was paid to the medical professional concerned.
Look at it this way. His total charge was £175. If I hadn’t noticed the £75 had been deducted in error, he would have received 43% less than he was perfectly entitled to be paid!
pete@medicalhealthcaremanagement.co.uk
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What on earth is that?
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 same by “inappropriate billing” is not the smartest way to go about it.
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One of the most often asked questions is “how as a private consultant surgeon can I improve or increase my cash flow”.
The answer, as regards medical invoicing, is very simple to answer:
But what does that mean in reality? It means taking all the items that should be done and turning them into a MUST be done. For example, I took a phone call from a consultant’s secretary this morning who wanted a favour. She was struggling to get an invoice posted electronically. She was trying to invoice BUPA. Simple enough you may think but despite having a policy number, she could not process the invoice.
So how did it take me approximately 3 seconds to work out precisely WHY she couldn’t process the invoice?
She told me the policy number began BI-6000 etc.
That told me the policy number was not a BUPA policy number; it was a BUPA INTERNATIONAL policy number. She was trying to invoice the wrong insurance company. A quick fix to process the invoice, again online, to BUPA International and it sailed through. Sorted.
If standards had been raised to ensure that every single patient registration form had been completed correctly, this problem would not have occurred. The invoice would have been processed the same day and payment made when required. Instead, a shortcut had been attempted and the patient’s insurance company detailed incorrectly. If standards had been raised to ensure this was checked and spotted the invoice would have been immediately processed. There are no shortcuts if you want to get paid. As it happens in this case the issue was already a week old before I took the phone call.
Thus an increase in cash flow – the outcome desired by the private consultant – was not being reached.
However, if you stop to think there are two questions:
When the patient was registered, why wasn’t the check performed to ensure the right insurance company was recorded because it should have. What should have happened was the standards had been set too low. If it becomes a case of the patient MUST be asked i.e standards are raised then this specific problem is never allowed to arise.
And that’s what I mean by raising your standards.
So why is this crucial?
Because more and more private medical insurance companies are insisting invoices be submitted electronically. The issue is not one of is that the right thing for them to do or not. The real issue is that it is happening and standards must be raised to ensure you CAN invoice electronically. In other words, if you don’t have all the right details it is much, much harder to process an invoice electronically. You will instead have to re-contact the patient and get the right details.
Therefore it makes more sense to say you MUST get the details upfront and you must RAISE YOUR STANDARDS to the point of saying – the correct details MUST be obtained and checked.
I’ve even witnessed where an invoice can’t be processed because the postcode has been recorded as W01 (numeric) when it should say W01 (alpha) Incidentally.
Many times I’ve said insurance companies are not the enemy. Even if I frequently disagree – I do on a daily basis sometimes – with some of their fees plus other items they do which are seriously irritating, all insurance companies will pay a private consultant IF (and only if) ALL the details are correct. In other words, invoices must be raised to the correct standard.
If you want to increase or improve your cash flow, the very first thing to do is to raise your standards in the area of invoicing.
pete@medicalhealthcaremanagement.co.uk
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There a few things I hear that automatically set alarm bells ringing when I look at the billing process of a medical practice.
“I’ll take a look at it next week”
“I’ll get round to it in a bit”
“I’ve been meaning to look at that”
The final of those items was said to me last week.
I was sitting on a panel facing an audience of medical professionals.
In amongst the various questions was one relating to how to monitor the invoicing efficiency of a medical practice.
To me the answer is simple. Before you can measure any part of a business, you must first establish a standard to measure against. Which is what I said to the questioner. I asked if he knew how many invoices he had raised last month and the total value of them. Sadly he didn’t know either.
But, I continued, to improve the performance of your practice you must know how you are performing against whatever standard you decide is appropriate.
Now consider the issue of invoicing with a real MHM example. One of my guys – a private consultant surgeon – saw 25 patients between Monday, August 20thth, and August 24th. Therefore I should see 25 invoices. That is an ultra-simple which makes sure everything is invoiced.
If I only have 23 invoices I have a problem!
But it also means of course at the end of August I can add up the number of invoices and also tell the client how many patients he has seen during August. Then we can compare that number with the number the previous year and see if it is higher or lower. The introduction of such a basic, basic, basic management control isn’t a nicety. It is an absolute necessity if you are going to manage the invoicing process effectively.
The audience member agreed fully but then the alarm bells went off when he said “I’ve been meaning to look at that for a while now” He hadn’t because there always seemed to be some other problem to deal with.
That tells me his management controls aren’t as robust as they should be. It also tells me he is suffering from one of the worst and easily avoidable causes of business failures out there:
Procrastination is even worse than having a backlog of invoices to raise because it diverts you from identifying a backlog is building up.
Procrastination is even worse than having no cash because it distracts you from raising the invoices and thereby getting paid.
Procrastination is the cause of the problem he has because various insurance companies have declined his invoices for treatment as the consultation was more than 6 months ago.
Set time aside every single week to make sure, you DO invoice and to make sure you review what is happening with YOUR money!
pete@medicalhealthcaremanagement.co.uk
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Two different MHM clients – both consultant surgeons – have been advised by a specific insurance company that the fees for their initial and follow up consultations 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 consultation 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 consultation 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.
It is worth noting that the drop in consultation fees would not impact in a drop of surgical fees because surgical fees were excluded from the reduction.
That said a refusal to see patients from the specific insurance company concerned due to consultation 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.
pete@medicalhealthcaremanagement.co.uk
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I trained a medical secretary in the noble art of medical invoicing recently.
Having your medical secretary handling medical invoicing isn’t something I’d recommend for a number of reasons. First and foremost, over the years medical invoicing or medical billing has become far too complicated to be done on an ad-hoc basis.
This is not to say a medical secretary can’t understand how to invoice. Of course, he or she can. Given enough time, effort and training the ability can be developed.
If you think about it there are only a certain number of hours in a working day.
Into those hours a whole multitude of tasks has to be done. In the case of your medical secretary most likely she’ll have to answer the phone, book clinics, answer emails, meet patients, take down patient details and generally act as the first port of call for any issue within your practice. And then sometimes is added the task of medical invoicing.
Invoicing an entire clinic list does NOT take that long – provided there are no interruptions.
Add numerous interruptions (the phone rings, the hospital want to alter clinic times or YOU want something) and medical invoicing will prove difficult. Then throw in incorrect patient insurance details – even MISSING patient insurance details – and the thing becomes a nightmare.
She was – and still is – very, very good at her job.
I spent enough time to train her and demonstrate what to do if a patient’s records were missing, where to find a CCSD code, how to find the correct fee from an insurance company. I also trained her how to allocate cash and deal with shortfalls and excess amounts deducted by an insurance company. She got it. All of it. She was more than capable of handling any medical invoicing.
She was very good at medical invoicing. Right up to the point she had to do it on top of her other aforementioned duties.
I did warn her this might happen. I did share my fears both with her and with the consultant. The consultant was firmly of the opinion that provided all the details were correct, there should not be a problem. But there was.
What was really significant was the med-sec telling both of us she was simply running out of time.
She would start the invoicing process at the end of each day around 5 pm (I taught her well) but before she had even blinked (her words) it was 6 pm and time to go home. So she tried to work faster.
Sometimes she’d undercharge a surgical episode. Sometimes she would omit to charge a consultation because she hadn’t got time to stop and correct the patient’s details that were wrong.
So she tried – and I truly admire her determination – to “fit” the invoicing in around all her other duties.
The whole invoicing process collapsed! It was fascinating to hear her talk about invoicing taking an hour each day when straightforward but take “ages” when it was not. She literally was losing track of time.
If that wasn’t bad enough losing track of time was having a knock-on effect.
She simply didn’t realise that other tasks she had to complete each day weren’t getting done.
Of course, this tale is all very interesting but what is the worth in it?
The worth comes from realising WHY the cash flow had suffered, WHY existing patients were starting to complain the phone wasn’t being answered and WHY new patients couldn’t make an appointment!
There are only a certain number of hours in a day.
Try and cram into those hours more than you can successfully achieve and you could very easily find your private practice in difficulties.
In other words, if you lose track of time, sooner or later you will lose money too.
pete@medicalhealthcaremanagement.co.uk
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Last year another of the major insurance companies – Vitality – announced they were no longer accepting paper invoices.
For years, MHM has argued paper invoices should be avoided. We submit invoices electronically. It has saved a fortune in postage costs.
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.
Invoices for self-funding patients should always be mailed to a patient. It is bewildering however that consideration is given to sending a paper invoice to an insurance company. Regardless of whether they allow it or not.
MHM supports those insurance companies who insist as part of them granting recognition invoices to them are electronic only.
pete@medicalhealthcaremanagement.co.uk
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Most consultants are concerned, quite rightly, with how and why a patient has chosen to see them. Before asking the question why and how does a patient choose you as a consultant an early question is asked. Why have the patients taken out private medical insurance originally?
There are three major reasons.
Empirical research on the patients of MHM clients indicates whilst most private healthcare originates via a patient’s employer, even if the insurance is paid for privately, the number one reason for holding private healthcare cover is to avoid and cut short NHS waiting lists. This is the primary reason patients have private medical insurance cover.
But whilst private health cover gives a prompt access to treatment, the second reason for having private healthcare insurance is that it offers the additional benefit of when and where the patient may be treated. Aligned to this is the ability to recover, if surgery is necessary, in a private suite, which is more convenient to both the patient and his/her family.
Thirdly, and finally, private insurance offers a choice of a consultant to the patient.
Before considering why a patient should choose to see you as a consultant, it is equally useful to consider why the patient has private medical insurance in the first place.
The major reasons patients choose to take out or receive private medical insurance are, in the main, three:
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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 a 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 were 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 usually, 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 £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. All that would happen, however, is the insurance company would reduce the value of the invoice down to the £100 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!
pete@medicalhealthcaremanagement.co.uk
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I was literally 70% through billing for a client’s clinic he held yesterday. Eight separate patients and a mixture of initial and follow up consultations.
All was going well until I noticed the details of one of the patients on the clinic list were incomplete. The only solution was to speak to the patient’s insurance company and get ALL the data required to bill effectively and efficiently.
So I called the insurance company but like many when you call them you join a queue and have to wait your turn.
So far I’ve been on hold for 16 mins.
Yet this problem could have been so easily avoided if the correct details had been taken down and checked. The problem was the policy number had not been recorded correctly.
Just got through and it transpires the date of birth is also wrong. Patient was born a year EARLIER than stated on the clinic list.
Three observations really:
If you are invoicing electronically, without the correct details you will not be able to invoice.
If the details had been checked originally before the clinic list had been produced, none of this would have been necessary and the invoice would have been processed for payment much quicker.
Finally, if your med-sec is handling your billing, whilst he/she is on the phone for 20 mins to an insurance company she’s not actually talking to patients and booking them in or typing your letters. Indeed patients can’t call her because she’s on the phone sorting out issues such as the above.
So it’s taken around 20 mins to sort this one single issue and that is what can take up so much time!
How many times have I said most clearly:
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A normal item when I get asked to review a consultant’s invoicing process is the potential for weakness in the area of records on his/her part.
Sometimes, I’m presented with a carrier bag full of invoices, remittances, and receipts. My favourite though remains the cardboard box stuffed full of pieces of paper and being advised that’s the filing system. Close examination of the pieces of paper in the cardboard box suggested they were
My favourite though remains the cardboard box stuffed full of pieces of paper and being told that’s the filing system. Close examination of the pieces of paper in the cardboard box suggested they were
Close examination of the pieces of paper in the cardboard box suggested they were invoices. Most did not have an invoice number on them. Indeed the majority did not actually have the word INVOICE printed on them either.
That can be a problem when I come to reconcile payments against such payments. IF they’ve been paid at all. That is important because it is difficult to contact an insurance company and discuss invoices for one individual patient if the invoice does not show an invoice number. In
In fact, the only way you can tell them apart is if the values are different and they are on different dates.
It’s always best to have a unique reference number on an invoice i.e. an invoice number and a date.
Then the hard part starts as you begin to look at what is or is not on the invoice and get a feel for what was likely to be paid anyway and what was likely to be rejected due to total lack of detail.
Normally this is followed by a request to see clinic lists and the process of obtaining the right data off the clinic list for submission to the insurance company.
There is also an additional cost to not keeping accurate records. When it comes to tax time, its going to take a lot longer – and thereby cost much more – for your accountant to do the necessary computations. At worse you could end up paying too much tax.
All because records aren’t kept correctly.
pete@medicalhealthcaremanagement.co.uk
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A consultant surgeon sometimes does not understand how valuable his time is.
All MHM clients 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. One prefers a Saturday morning. 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 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. Patients are paying to see me so they must come first”
I agree with him.
Sadly however 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 “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 as well. 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.
pete@medicalhealthcaremanagement.co.uk
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There a few things I hear that automatically set alarm bells ringing when I look at the invoicing and billing process of a business.
“I’ll take a look at it next week”
“I’ll get round to it in a bit”
“I’ve been meaning to look at that”
The final of those items was said to me recently at a medical conference in London.
I was sitting on a panel facing an audience of medical professionals who wanted to ask what made a medical practice successful.
In amongst the various questions was one relating to how to monitor the medical billing of a medical practice.
To me the answer is simple. Before you can measure any part of a business, you must establish a standard to measure against. Which is what I said to the questioner. I asked if he knew how many invoices he had raised last month and the total value he had invoiced. Sadly he didn’t know either.
But, I continued, to improve the performance of your practice you must make sure you know how you are performing against whatever standard you decide is the most appropriate.
Now consider the issue of invoicing with a real MHM example. One of my guys – a private consultant surgeon – saw 25 patients between Monday, January 16th, and Friday, January 20th. Therefore I should be able to see 25 invoices.
That is a simple but effective control which makes sure everything is invoiced. The standard has been set because one invoice is required for each patient.
If I only have 23 invoices I have a problem!
But it also means at the end of January I can add up the number of invoices and also tell the client how many patients he has seen during January. Then we can compare that number with the number the previous year and see if it is higher or lower.
The introduction of such a basic management control isn’t a nicety. It is an absolute necessity if you are going to manage the invoicing process or indeed the whole business effectively.
The audience member agreed fully but then the alarm bells went off when he said “I’ve been meaning to look at that for a while now” He hadn’t because there always seemed to be some other problem to deal with.
That tells me his management controls aren’t as robust as they should be. It also tells me he is suffering from one of the worst and easily avoidable causes of business failures out there:
Leads to a backlog of invoices because it diverts you from identifying a backlog is building up.
Is even worse than having no cash because it distracts you from raising the invoices and thereby getting paid.
Procrastination is the cause of the problem he has because various insurance companies have declined his invoices for treatment as the consultation was more than 6 months ago.
Set time aside every single week to make sure, you perform a sanity check. Make sure you DO invoice. Make sure you review what is happening with YOUR money!
pete@medicalhealthcaremanagement.co.uk
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A question we were asked very recently. One, in fact, we are asked frequently. But what is the problem?
There are a few very simple reasons why online invoices are not being accepted. The details being submitted are incomplete and/or the details being submitted are wrong.
MHM is a big fan of electronic invoicing. But electronic invoicing does depend totally on one item. Having the correct data. For example: if you try and invoice electronically you will need the patient’s date of birth and the patient’s postcode. If either is incorrect then you will NOT be able to invoice.
This goes back to a consistent requirement of making sure you the details are correct.
The first and ONLY place to start is the patient’s registration form.
If this form is not completed or there are errors, the problem will manifest itself in the fact an invoice can’t be raised electronically.
In 2017, MHM was asked to review the billing of a large medical practice. The issue was the practice was owed significant amounts of money and could not get paid by one specific insurance company. MHM reviewed 100 invoices all of which had failed to be accepted.
In over 60% of the cases either the patient’s, policy number was missing or date of birth was missing or the patient’s postcode was wrong.
The practice manager responsible for this had, to resolve the problem, decreed the invoices should be sent in paper form instead. A clear case of mistakingmovement for action!
The insurance company concerned, remember, had stated invoices should be sent electronically and ONLY electronically.
There is no such thing as a quick fix. A quick fix – such as sending invoices in paper form – often leads to more problems as it does not resolve the cause of the issue. Many insurance companies will no longer not accept paper invoices anyway so you might as well get it right up front.
MHM suggested going forward ALL patient details were captured correctly and the data verified with NO exceptions. We then took the “old” invoices and corrected/completed the data.
Within 4 months the average monthly cash flow into the practice had increased from around £120k a month to £260k a month.
pete@medicalhealthcaremanagement.co.uk
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I’m often asked who is actually responsible for paying an excess or a shortfall.
Interestingly the question was asked recently 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. They would be collecting excess or shortfall amounts from the patient on his behalf.
The responsibility for 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.
So, when the patient claims the cost of your services from their insurance company there could well be excess for which the patient is liable. You, however, are responsible for collection.
The patient’s insurance company is not responsible.
The consultant who asked the question called a few days later.
To his horror, he had over £5,000 worth of uncollected excess in the previous two years unpaid which nobody was collecting.
The real question however is:
pete@medicalhealthcaremanagement.co.uk
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This specific issue comes up frequently when MHM is asked to review the outstanding accounts of a private consultant surgeon.
There are two reasons normally why the patient believes the hospital has already taken payment.
When the patient is registering at the hospital, he/she is frequently unaware or never even told the card details are for hospital fees only.
To overcome this, MHM recommends the client’s invoice bears the message “payment of this invoice is not covered by any debit/credit card details taken by the hospital”
To further help prevent the issue arising, MHM recommends that when the patient makes the booking for the initial consultation, he/she is told an invoice will be sent to them after the consultation.
Over the last year, twice MHM has amended the surgeon’s invoice to include the above sentence. In both cases, the number of outstanding self-funder invoices reduced.
The second reason is that the patient had a “package” with the hospital. Obviously, the package covered the patient’s stay, surgery, anaesthetist and, most likely, follow up consultations.
This happens more often than is thought!
To resolve this issue MHM contacts the patient and request they check what was and what was not covered in the package. Payment of the surgeon’s initial consultation fee soon follows as the patient agrees the initial consultation fee is not covered.
BUT again when the consultant’s secretary confirms all items with the patient, the patient should have been advised the initial consultation was not covered.
Whilst there are in the real world some patients who do not pay upon receipt of an invoice, the vast majority do not pay or react to the invoice because they genuinely do not believe they owe any money.
pete@medicalhealthcaremanagement.co.uk
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Surgeon A is an ENT consultant surgeon. He performs an E1910 on two different patients. The surgeon bills both patient’s insurance company £1,600 each.
Patient ONE’s insurance company fee structure is £1,600; Patient TWO’s insurance company fee structure is £1,945 for the same episode.
By invoicing Patient TWO’s insurance company £1,600 i.e. the fee he gets from Patient ONE’s insurance company, the surgeon has undercharged.
The surgeon will be paid £345 less than he should.
A similar issue was faced by Surgeon B. He is a gynaecologist. He has the same issue. He performs a Q0800 on two different patients who are insured by separate insurance companies. He invoices both insurance companies at £636 each.
Patient ONE’s insurance company’s fee structure is £636 however whereas Patient TWO’s insurance company’s fee structure is £800.
Surgeon B, by using the fee structure for Patient ONE only has undercharged and been paid £164 less than he should.
Both carry on billing not realising that the fee depends on whom the patient is insured with and different private medical insurance companies publish different fees for the same surgical procedure.
We checked four different medical insurance companies this afternoon in order to confirm the fees for an E1910. The fee were £636, £676, £775 and £800.
We then turned to Surgeon B and the medical code of Q0800 and found the fees were, dependant on which of the four medical insurance companies we checked, £636, £676, £775 and £800 respectively.
Don’t set fees at the level published by a single insurance company.
Check which fee is paid by which insurance company for the same procedure. Do not assume they are the same because they may not be.
A surgical fee can and does alter between private medical insurance companies. It can also alter over time.
In every single case, it’s always worth checking the fee structure paid by the patient’s insurance company. Do not assume it is the same across all private medical insurance companies.
Invoice for two different codes in the same surgical episode incorrectly and it is easy to get into even more trouble. For example Insurance Company X may allow 100% of the higher value code and 50% of the second but Insurance company Y may allow 100% of the first but only 33% of the second.
Imagine what happens if all episodes are billed at 100% and 33%.
Immediately you’ve lost 17% of your second fee!
pete@medicalhealthcaremanagement.co.uk
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A normal item when I get asked to review a consultant’s invoicing process is the potential for weakness in the area of records on his/her part.
Sometimes, I’m presented with a carrier bag full of invoices, remittances, and receipts. My favourite though remains the cardboard box stuffed full of pieces of paper and being advised that’s the filing system. Close examination of the pieces of paper in the cardboard box suggested they were
My favourite though remains the cardboard box stuffed full of pieces of paper and being told that’s the filing system. Close examination of the pieces of paper in the cardboard box suggested they were
Close examination of the pieces of paper in the cardboard box suggested they were invoiced. Most did not have an invoice number on them. Indeed the majority did not actually have the word INVOICE printed on them either.
That can be a problem when I come to reconcile payments against such payments. IF they’ve been paid at all. That is important because it is difficult to contact an insurance company and discuss invoices for one individual patient if the invoice does not show an invoice number. In
In fact, the only way you can tell them apart is if the values are different and they are on different dates.
It’s always best to have a unique reference number on an invoice i.e. an invoice number and a date.
Then the hard part starts as you begin to look at what is or is not on the invoice and get a feel for what was likely to be paid anyway and what was likely to be rejected due to total lack of detail.
Normally this is followed by a request to see clinic lists and the process of obtaining the right data off the clinic list for submission to the insurance company.
There is also an additional cost to not keeping accurate records. When it comes to tax time, its going to take a lot longer – and thereby cost much more – for your accountant to do the necessary computations. At worse you could end up paying too much tax.
All because records aren’t kept correctly.
pete@medicalhealthcaremanagement.co.uk
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