Recently a friend of mine called asking for a favour.
I’ve known this guy years. We started our respective businesses around the same time.
He has now reached the point where he needs to relocate his staff to a new building. As his business continues to expand, he has simply run out of room.
As he wanted to move from where he is now to Wolverhampton and as I obviously know the area better than he, would I have a look at offices that are available and get back to him?
Sure, no problem.
You are paying next time we go for a curry.
So that afternoon I looked on Google to see what was available.
Having identified possibilities it was time to get the details. So I called the first four agents. I explained the premises were not for MHM but for a client who’s identity at this stage was confidential.
We were looking for premises that could seat 15 people plus two offices (one for MD and one for the General Manager).
We also needed on-site car parking. I also explained this was very much an initial inquiry and I was merely establishing what, where, how much, etc.
I asked them to e-mail potential premises and give me a week to consider the options.
After giving it some thought, I’d call them back after there week had passed.
Nothing would happen before that.
Why then have I taken three phone calls this morning asking me to update them and enquiring how we move forward?
Again I repeated this was an initial inquiry and pointed out nothing would happen until my friend and I have looked at the details. But still, I was asked the same questions I’d already answered.
The decision would not be taken for the next seven days
I don’t want to arrange a viewing of a specific property yet
I’m not able to state who my client is
I’m not interested in them coming to see me and discuss requirements
Premises for 40 people are NOT suitable – I said up to 15!
Offices for 6 people with no car parking is a stupid suggestion.
If I hadn’t got to find the best possible premises the three who hassled me this morning would drop straight off the list and I’d only deal with the remaining agent. And for one reason alone.
She has accepted and understood the brief and instructions and therefore she goes to the top of the list.
Two of those who hassled me have the same property available as the one who has NOT hassled me. And the premises look very suitable too.
Now let me think whom I’m going to call back?
The lady who did NOT hassle me!
My point is I gave a very specific brief to all four.
It does not instill me with much confidence regarding the three who don’t appear to be willing to follow even that.
I know all four have a job to do but wasting my time by calling is unacceptable.
Final thought, the one agent who called my mobile this morning because my direct line was engaged should maybe have considered my direct line was engaged because I was USING IT!!!
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What follows is absolutely real and why medical invoicing can be more troublesome than it need be.
One of my guys ran an outpatient clinic last Thursday
The clinic list arrived with me on the following Monday. There were 8 patients: 3 initials and 5 follow-ups.
Within 30 minutes 7 invoices had been produced and delivered to the various insurance companies. But that final EIGHTH invoice caused significant issues. Why?
So I rang my client’s medical secretary and ask if she knew what they were. The FIRST phone call – I’m told the patient is with insurance company A but did not know his policy number.
Length of the phone call: 5 mins
2. a SECOND phone call was necessary.
This time to the insurance company. I was on hold for 11 minutes to this particular insurance company which is about normal for this insurance company. Some are 4 – 5 minutes.
With some, you are on hold for considerably longer.
Once I got through however despite having the correct name, date of birth and postcode I was informed the patient’s policy had lapsed.
Length of the phone call: 11 minutes plus 5 minutes = 16 minutes.
3. A THIRD phone call was made. This time to the patient.
Answer machine so I left a message to call me back. He did. The patient confirmed it was totally the wrong insurance company.
He told me the correct insurance company but did not know his policy number!
Length of phone call(s) 5 minutes
4. A FOURTH phone call to the second insurance company.
Placed on hold for TWENTY-THREE minutes!
Finally, get through and I’m advised the correct policy number, etc. Invoice raised.
The total length of phone calls: 49 – FORTY-NINE MINUTES!!
There is no problem in spending 49 minutes on the phone; none whatsoever.
But just consider the problem if the medical secretary at the same time as that had patients trying to speak to her? Or she had correspondence to get out? Or she had clinics to book? She would have struggled.
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So patient arrives for the consultation without a pre-authorisation.
What should the private practice do?
Ask the patient to ring their insurance company and obtain the pre-authorisation. But….
If the consultation is for Thursday October 14th and the patient does not call until Monday October 18th, the patient must tell the insurance company.
In this example, the patient did not tell the insurance company which date.
When MHM raised the invoice, it was declined.
The consultation was before the date of the pre-authorisation.
If the insurance policy that won’t allow the backdating of a pre-authorisation there will be more difficulties.
In this case an invoice is sent to the patient.
The insurance company is not being unreasonable.
The patient is incurring a liability on their behalf.
The insurance company knows nothing about it. But ultimately the patient is liable for the consultation and thus the invoice is sent to the patient.
The patient rings up (normally upset) and points out they have insurance.
Numerous phone calls between the patient and the insurance company follow.
It would have been better IF the patient had told their insurance company the consultation is for a specific date.
If this is happening to you, it’s an issue you must address.
Otherwise you will spend 15 – 30 mins just sorting this one problem out!
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One of the most common remarks I hear from my guys is the number of patients they see in the NHS. Such comments are normally followed by the opposite when discussing a private practice.
They want to see MORE patients.
This, for me, confirms the cultural difference between the public and private sector.
In the NHS, a consultant surgeon does not have to do much in order for patients to be delivered to them.
In the private sector the opposite applies.
In the private sector a consultant surgeon, MUST do everything he or she can to attract a patient.
He must ensure it is known his practice is there.
First of all however he must comprehensively understand WHY a patient is choosing to go private. It is not just the case of a patient wanting to be seen private because he or she has medical insurance. It is understanding WHY the patient has medical insurance.
More likely it is because the private patient wishes to be seen quicker.
Even so, a consultant surgeon MUST engage in marketing of whatever description.
Therefore a marketing plan, is an integral part of a private consultant surgeon’s business plan.
And therein lies the reference to the cultural difference between an NHS practise and a private practice.
A Private Practice is a business.
In a NHS practice, patients will be delivered to the consultant surgeon.
In a private practise, this won’t happen. They must be attracted to the practice or more accurately to the business.
Note the use of the word BUSINESS. A private practice is a business.
This is not the time to discuss which marketing strategies work best for a private surgeon. This blog is concerned with highlighting the differences between the NHS and the private sector and therefore private consultant surgeon must have a marketing strategy.
Just has a consultant must have a robust infrastructure to support the business (secretarial support, invoicing, banking etc), it is equally as important to have a marketing strategy.
Look at it this way, if any business does not have a regular number of clients or patients then the business will not succeed.
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Many MHM clients have asked what I think the future holds for their fees?
A number of private insurance companies have reduced fees for consultations and for surgical episodes over the last few months and years.
One insurance company, for example, dictated newly recognised consultants must accept lower fees than their colleagues who had been recognised some years earlier. It was inevitable that at some point the previously recognised consultants would be asked to accept the lower fees too. And that point was reached recently looking at some of the emails forwarded to me.
Certainly, the more established consultants can and have tried to refuse acceptance of the new fees.
Some have accepted the new lower fee but decided to pass the difference between the old and new fee on to their patient as a shortfall. Their solution has been problematic. The refusal has often been met with the threat of de-recognition by the insurance company concerned.
I know of one consultant surgeon who instructed “gap” invoices should be sent to the patient. An invoice for the difference between the old, higher fee and the new, lower fee. He wasn’t an MHM client otherwise I would have told him what was likely to happen.
The act of issuing an invoice and passing on a shortfall by a fee assured or fee guaranteed consultant will and has resulted in the same de-recognition scenario.
Whilst MHM never has and never will be in favour of constantly reducing consultant’s fees, the often quoted insurance company argument of fees being dictated by “market forces” is both mischievous and, in some cases, wrong.
And if somebody else tells me the Covid-19 pandemic has forced all insurance companies to re-examine their fees, I’ll scream. Covid-19 is nothing to do with it!!
But we are where we are.
What is disturbing though is when MHM talks to new clients the number of cases where the maximum correct fee has not been charged. More specifically, where a lower fee has been charged that the insurance company was happy to pay.
Insurance companies do have a habit of reducing fees.
But they increase fees too.
Certain surgical fees have gone up recently. Fees should be checked very regularly to make sure you ARE charging the right fee.
So, what next for a private consultant’s fees?
The assumption has to be that pressure on fees to reduce will continue.
Nonetheless, the assumption the private consultant is charging the right fee in the first place should and must be challenged for you may, in fact, be undercharging.
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I’ve been reading a really interesting book.
The book goes into some detail on how decisions are made.
What the process is?
Which factors are included?
Why are some factors excluded?
When is a decision made?
Why has a decision been made?
I could read about things like that all day. Probably because I’m sad.
The book reminded me though of a group of surgeons who commissioned a review of their practice recently. The issue concerning them was the amount of money they were owed and the ineffectiveness of the attempts to reduce it.
Consequently, I spent a couple of hours looking, listening, probing and establishing the CAUSE of the issue.
Or as my old mentor and teacher used to say to me every single time I was given a project: ESTABLISH THE FACTS.
In the case of the group of surgeons mentioned earlier, this itself was problematic.
Whilst it was very easy to establish the practice was owed huge amounts of money, it was not so easy to establish WHY. That is until I witnessed how the practice was being run.
In one single month, there were 36 separate consultations worth £4,500 which could not be invoiced. Why?
Because the senior consultant surgeon had instructed the medical secretaries not to ensure the patient’s details were correctly obtained at the point of registration.
It was more important, in his view, that the patients were registered quickly and professionally.
No argument from me on that point. However, that one single decision taken without thought as to the full consequences was the cause of numerous issues.
The consultant surgeon concerned took great pride in his ability to take instant decisions.
It never occurred to him though that you don’t always have to take an instant decision. Indeed most of the time it is better not to.
Notwithstanding that, when I spoke to the senior consultant he would not accept the need for the correct details to be obtained.
In his view the details being obtained were sufficient. That is fine IF his view is correct. Sadly it is not correct. His view, very respectfully, was not the one that mattered.
The view that did matter was the one held by the various insurance companies to whom an invoice would be sent.
They held power. In other words, if their standards were not being met then they would refuse to accept an invoice let alone consider paying it.
In the case of the group of surgeons I was working with, the invoices could not be raised because much of the mandatory data needed was missing.
Many times I’ve argued with an insurance company. Not one single insurance company but all of them at one point or another.
My job is to ensure my clients get the very maximum they can for their work.
If an insurance company make a mistake – it actually happened last week with one of my guys when the insurance company rejected an invoice as being a duplicate of another invoice (it wasn’t) – then I go into bat and argue the case.
Normally I win too.
But I will never object to an insurance company insisting medical invoicing is done correctly.
There are no excuses for doing it incorrectly.
The only outcome if a consultant surgeon does not ensure that his or her invoicing is done correctly is simple: the insurance company won’t pay.
Returning to the group of surgeons mentioned earlier, it was clear WHY they were not getting paid. They were not invoicing correctly.
And that is the one topic I’ve always driven right at.
Instead, the consultant surgeon concerned was issuing immediate instructions at the medical secretaries in the practice when faced with an invoicing problem to “ring such and such straightway” or “go to reception and get this done before anything else” or “immediately do this instead”
But the decisions he was taking were themselves causing subsequent issues.
He had forgotten or was ignoring the necessity to get things right the first time. For example: when the patient registers with the practice make sure you get ALL the patient’s details correct.
“That is only a small item so can’t be that important” came the response from the Consultant Surgeon concerned.
To his credit, he agreed to stop firefighting and concentrate on getting the details right first time
In the first month, the number of episodes which couldn’t be invoiced fell to 1. The value which could not be invoiced fell to £125.
Cash input into the practice shot up an amazing 756%
All because instant decision making has stopped.
All because the invoicing was now being done correctly.
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The single biggest restriction on the performance of any private medical practice is:
Sound surprising? It shouldn’t be.
There are only 24 hours in a day. Even Stephen Hawking (one of my heroes) can’t alter that.
If there are only 24 hours a day, the hours have to used in the most efficient manner possible.
The interesting thing when I first look at ANY medical practice is therefore what is being done during those 24 hours. In reality, of course, most staff within a practice are only there between 7 1/2 and 8 hours daily.
Normally comments suggesting there are not enough hours in the day are common. This is usually followed by “lots of really, really urgent problems to sort”.
Have you ever stopped and considered what causes problems to become “urgent”?
Most of the time, they are deemed urgent because the cause was never considered or thought through originally.
Or maybe the original task was not fully completed?
Take the example of a hospital group I was working with last year. During a single month, 85% of its invoices failed electronic submission. This led directly to the requirement for a medical secretary to look at them “urgently” and get them sorted. 85% is a HUGE number.
MHM failure on electronic submission of invoices is 0.75%
When the failures were examined, there were instances where the policy number had been recorded as ‘To be advised” or a patient’s postcode marked as “to follow”
An attempt to invoice without both items is almost certain to lead to invoicing difficulties.
So why was the hospital group failing to fully complete tasks so often compared with MHM?
Quite simply because MHM continually stresses the importance to its clients of making sure absolutely all data required to raise an invoice is obtained right at the start.
Even when MHM receives the data, its checked before an attempt to raise an invoice is even made.
In other words, concentrating on what is IMPORTANT reduces the number of times an issue becomes URGENT.
This does not generate more hours in the day.
It does, however, mean the hours that are available are used as efficiently as possible. But how do you use the hours effectively?
Personally, I use the good old Pomodoro time management technique.
Laugh if you want but it works for me. Today, for example, I have an avalanche of work to do. In between I’ll have the normal influx of emails to respond to, calls to make, clients invoices to raise, remittances to receive plus client’s reports to send out. It WILL all get done. How?
I arrived in the office at 8 am. I looked at the list of tasks on my ICAL prepared the evening before and started Pomodoro.
Put very simply I have a timer on my IPAD that counts down from 45 minutes.
Then I start on my first task with total concentration. After 45 minutes I stop, check emails and go make a coffee. After 15 minutes I start again.
Another 45-minute slot. If I finish one task, I immediately start concentrating on the next. After 45 minutes, I stop once again and check my emails.
After the second 15 minutes, I start again. Never will you find me checking emails during a 45-minute slot because that would break my concentration.
It helps of course that I do not have the email alert switched on.
This continues until ALL the tasks are done.
At 5 pm I stop whatever it is I’m doing and check all the tasks completed during the day, think about anything that needs to be revisited on the next day and add them to my ICAL.
Pomodoro, therefore, breaks the day up, keeps me focused and forces me to work in highly concentrated 45-minute chunks.
It means I have to stop staring at an iMac screen for hours at a time and getting a headache too.
It also means the tasks that are IMPORTANT receive the level of attention they deserve.
As a result, I rarely find myself facing anything that is URGENT.
By the way, Pomodoro is Italian for tomato. The technique was devised by Francesco Cirillo in the 1980s and based on a tomato-shaped timer. Hence the name!
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Following last week’s article regarding how you should always keep good relations with a private medical insurance company, it is worth pointing out that this does NOT mean you have to agree with them.
The following incident, for example, happened this week.
An MHM client recently performed a Q1800. The episode was pre-authorised (meaning the patient’s policy was intact). The fee was £280.
Then the problems started. The insurance company paid the consultant £103 so I called and asked why.
Post the issue of the pre-authorisation, indeed after the surgical episode itself took place the published fee had been reduced to £103.
£177 or 63%!!
A number of issues immediately came onto the table.
Firstly, the fee of £280 applied at the point the surgical episode took place. It was wrong for the insurance company to reduce it afterward.
Secondly, £103 is a ridiculously low fee for a Q1800.
It is precisely the same fee as payable to the anesthetist working with the consultant during the surgical episode. At the risk of upsetting my anesthetist friends out there, that can’t be right.
Thirdly, the fee is lower than the surgeon’s initial consultation fee when he saw the patient in the first place.
A Q1800 (so I’m told) is not a minor procedure that can be carried out during a consultation. It is a “full” surgical episode requiring a theatre, anesthetist and theatre staff.
Thus I had a lengthy conversation with the insurance company concerned and advised them, should they insist the fee remained £103, we would be sending a shortfall invoice to the patient for the additional £177.
Normally, that is NOT a step I would take.
All MHM clients are advised to set their fees precisely in line with those of the relevant insurance company.
On this occasion though, I genuinely thought, and still do, the actions of the insurance company were unacceptable.
It is wrong for an insurance company to reduce a fee after a surgical episode.
A heated discussion took place regarding my view and that of the insurance company concerned.
They remained firmly of the opinion it would be wrong for MHM to send an invoice for the £177 shortfall to the patient. Absolutely not in my view for the “contract for treatment” is between the consultant and the patient.
A fact, insurance companies point out to me with frequent monotony. It is the insurance company’s actions that had led to this action.
Nor is it relevant that other consultants in the same specialism have accepted the fee reduction.
I’m not acting for them. I’m only interested in MHM consultant surgeons.
A fee of £280 was originally agreed upon. That is the fee which should be paid.
Finally, the insurance company agreed it was unacceptable to reduce a fee after the date of an episode. Therefore the additional £177 will be paid.
But in the future, the fee for a Q1800 would be £103. That is an issue for another time but I can foresee further conflict if other fees are reduced by 63%.
Do not however always accept a private medical insurance company are always correct in their actions and decisions.
Whilst the majority of decisions are acceptable, sometimes they might not be.
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My Top Three Assumptions when there is a knock on the office door are:
What on earth has that got to do with medical invoicing I hear you ask?
Maybe not the first two (definitely not the 1st although the 2nd may have possibilities). The 3rd, however, is very relevant for you really need a positive attitude when you are invoicing for consultant surgeons.
All my guys (and girls) are lovely. They really put some serious hours in. Seldom do they seem to sleep (a throwback to being at med-school and being a “junior” hospital doctor).
Joined up writing is an issue too – I’m being serious!
It is the joined up writing part where you need positive thinking. I once enquired of one of my clients as to why all medical professionals seem to have poor handwriting.
He responded that a Doctor’s ability to write legibly is surgically removed at med-school. Works for me.
I can’t really insist my guys and gals improve their handwriting. But I can and do urge them to send me the clinic lists produced by the hospital instead of writing them out again.
Why re-write something when you can scan the original anyway?
Consequently, that is what they do.
This leads me to have a positive outlook because I know the information I need will arrive in a format I can use to raise invoices correctly.
It also means from the consultant’s point of view once I have the data all the patient details will be checked. All the fees will be calculated. Invoices WILL be raised. I don’t even have to attempt to read the writing.
All in all, a very positive thought.
My clients, therefore, think positively regarding when and if they are going to get paid.
In reality, however, I don’t for a nanosecond believe in the concept of positive thinking.
You may, for example, have numerous positive thoughts that it won’t rain today. Your thoughts will have absolutely no impact at all on the weather and you may (or may not) get wet.
What will have an impact is if you have an umbrella with you? If it doesn’t rain, you won’t need the umbrella. Should it rain, you will.
If you have PREPARED and made sure whether it rains or not, you are in a position to handle it. You have taken ACTION.
It is just the same with medical invoicing.
Don’t just have positive thoughts that all your work is being invoiced.
Have positive thoughts that you will get paid the right amount and on time.
Take positive ACTIONS to make sure your invoices are being raised to ensure you do get paid the right amount and on time.
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It is depressing the number of times I hear potential clients rubbishing insurance companies.
In my experience the reasons normally cited are incorrect. Far from it.
I’ve lost track how often I’ve been told an insurance company won’t pay for something.
Yet when I ask if the insurance company have actually been asked IF they will accept a charge, the answer comes back that they have not.
I have all the private medical insurance companies on speed dial.
They need to be as I speak to most of them every single day of the week. There are many, many things I’m already aware of.
There are also some things that I don’t know or more importantly, that may have CHANGED.
I ask them all sorts. For example – I ask them to confirm a patient’s policy number.
I ask them to confirm why an invoice has only been partially paid.
Sometimes I ask them if I can or cannot charge for a certain medical episode. Which brings me neatly to the W9040 code.
I was invoicing for an orthopedic consultant surgeon recently. His specialism was knees and during a follow-up consultation, he administered a W9040. This particular CCSD code represents an injection into a joint or soft tissue.
The question arose if I could charge a particular insurance company for a follow-up consultation fee AND a fee for the injection.
So I called them.
The answer came back yes I could. I could charge £120 for the consultation and £50 for the injection i.e. £170.
The insurance company would happily pay such an invoice.
Compare and contrast that with work I was performing for a dermatologist recently.
This time the question arose of an S5210 (an Injection into subcutaneous tissue). I’ve only recently started invoicing for this client and thus it was important to establish what could and could not be charged for.
More specifically, would the insurance company accept an invoice for the follow-up consultation AND the injection? Yes, they would.
£125 for the consultation and £108 for the injection i.e. £233.
Remember however that I had asked ONE specific insurance company.
When I asked others the same question, some would NOT allow the separate charge.
What was concerning was previously the dermatologist had not been charging for the S5210 at all.
I actually asked his practice manager why this was so.
The answer came back that the question had been asked of an insurance company before and the answer was no.
The problem was that whilst that insurance company concerned did not (and still don’t) allow a charge, other insurance companies DID allow a separate charge. But nobody had asked the other companies.
Instead, it was assumed the decision covered ALL insurance companies.
Thus on numerous occasions, insurance companies are wrongly blamed for their actions.
It was only by speaking with the individual insurance companies that I identified which ones would accept the charge and which ones would NOT accept the charge.
Insurance companies are NOT the enemy.
If you call them, you may be surprised at what you are told.
That is not to say you will always obtain a positive response but more times than not you may.
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A few weeks ago, I was checking what was happening with shortfalls and excess since the start of the year. Using a single private consultant surgeon as an example:
Week ending Friday, September 17th, 2021: out of 15 consultations 4 came back with excess/shortfall deductions. The total £575.
So for a total of £2,500 worth of outpatient consultations £575 or 23% came back short.
Looking back to the same week in 2020, the number of shortfalls/excess was considerably less.
The question as to why this is happening is not the immediate concern although I will blog about that next week if anyone wants me to?
The concern is what you should do about it.
If 23% of submitted invoice values continue to come back as shortfall or excess, the downside and potential loss to a consultant surgeon is significant.
What to do about it?
The very first thing to do is to make sure the patient has been invoiced for the amount due immediately. If payment is not received within a week then there is only one subsequent single course of action.
Phone the patient.
Once I have the patient on the phone I take payment via a debit or credit card.
Sure you can write letters and even email but nothing gets a response like a ringing telephone.
Most patients are unaware of the issue (yes I know when they open their policy they are made aware of excess values) but some think this is an issue between them and their insurance company.
In other words, the patient thinks they need to pay the insurance company because the consultant gets paid in full by the insurance company.
There are variations on this but the crucial point for the consultant is not to establish why. The point is to ensure he recovers the shortfall/excess efficiently.
That means speaking to the patient.
But if telephoning the patient is the most efficient way to tackle the issue, it does not automatically follow its the easiest.
It has to be done professionally and with care.
This is not a debtor I’m talking to on the telephone.
It is a PATIENT!
The long-suffering med-sec really won’t have the time to do this as professional and caring as she undoubtedly is.
The majority of medical secretaries won’t want to phone patients for money and will be thinking this is the least enjoyable part of her job.
What if the consultant doesn’t employ someone to tackle this? What if they don’t do anything?
Assume it’s not £575 or 23% a week or £27,600 a year (£575 multiplied by 48 – not 52 weeks as you will have 4 weeks off a year).
Assume instead its 10% for 24 weeks (i.e. roughly half) and allows for some patients paying without being contacted.
That’s still £13,800 per annum.
What’s significant is that when speaking to a group of private consultant surgeons I asked what they considered the biggest threat to their practice(s).
Most popular is the anticipated further reduction in fees paid by private medical insurance companies.
There is little if anything that can be done about that.
The second concern, however, is the number of shortfalls and excess. It’s becoming a big challenge. A challenge that will get bigger in my view.
At this point, empirical evidence suggests its potentially leaving the back door wide open and enduring £13,800 worth of potential losses right off the bottom line.
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Banks are desperate to phase out cheques.
This is due to the cost of processing a cheque from the bank’s point of view.
Yet the decision was taken not to, as planned, phase out cheques completely by 2018.
It just is not going to happen. Cheques it would appear are here to stay.
But still, a number of consultants are reluctant to accept debit/credit cards.
Many MHM clients have endured problems with obtaining payment from self-funders and/or payment in respect of shortfalls and excess payments.
Even when a cheque has arrived, it must still be taken to a bank and paid in. And that is precisely why MHM has always advocated that a consultant must be able to take payment over the telephone.
In certain cases, dependant on the size of the practice, they should also be able to take payments online.
Yet this presents a dilemma for the consultant who believes rightly or wrongly that he/she cannot afford to accept payments over the telephone.
To MHM this is a false economy because frankly, we’d rather meet the cost of processing a debit or credit card payment ourselves than the client not get paid at all.
That is precisely what we did.
And it’s why MHM clients have a low number of outstanding self-funding patients and a low number of outstanding shortfall/excess amounts.
Just imagine the situation when the patient calls and offers to pay the account only to be told the consultant can only accept a cheque or a BACS payment?
In this scenario we are, at that precise point, actually refusing the offer of payment from a patient.
That cannot be a sensible approach for private medical practice, as a business, to take.
If the private practice is a business (of course it is) then it must conduct its business in an efficient manner.
To do otherwise leads to inefficiency and thereby a reduction of maximum profit available. As long as the payment methods are not to the detriment of the patient.
We once infamously advised a potential client, we were NOT prepared to charge the patient an extra 5% if paying by card.
The answer to the question is a resounding yes!
Indeed, whilst writing this blog I looked at my own cheque book. I’ve written out ONE cheque since October 22nd, 2014. All payments made by MHM have been by BACS, standing order or debit card.
Yet I must have processed hundreds of debit cards and credit card payments over the telephone on behalf of MHM clients in respect of self-funding invoices and/or shortfalls and excess amounts.
Do you need to take card payments over the telephone?
Well, we do it for our clients anyway!
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Recently I was reading an article in a business management magazine.
The article highlighted some of the challenges faced by small business owners when they start.
But it could also have been written about a consultant surgeon starting a medical practice.
The article illustrated how many small business owners attempted to start their business without assistance.
It is therefore common subsequently for the business to struggle with, for example, a lack of customers or a lack of cash.
This is normal for a consultant surgeon starting a private practice too.
It is not easy to start a private practice. There is a huge amount to be considered.
The basic rule is that if it can go wrong it will go wrong.
It happened when I formed MHM too.
Despite 35 years worth of managerial experience in running a business for various employers, I was used to ringing IT and having them install a new computer.
As a small business, ALL of that had to be done by myself. I soon realised, even though it cost, it was much better to go out and find someone who DID know what to do.
The first item in the article stated the first challenge facing a new small business is a lack of clients.
The same situation a newly established private medical practice faces too.
The second item was the lack of cash.
When I go meet a prospective client both are mentioned. Regarding the second point, the amount of cash generated by the small number of patients is nowhere near what was expected.
Yet I recollect when speaking to a colleague who specialised in marketing for consultant surgeons, most practices do not have a process in place to utilise the positive experience enjoyed by existing patients.
Their lack of new patients could be helped by using testimonials from current patients. The new practice does not have the right marketing strategies (both online and offline) to attract patients consistently.
Instead, marketing is left to drift.
My colleague is an expert at medical marketing yet she suffers from consultants believing she is too expensive to engage.
Alternatively, the new private consultant surgeon has a conversation with a colleague who has an established practice.
Hopefully, this pays dividends but it does suppose the established surgeon is maximizing his own marketing efforts.
Precisely the same happens when the subject turns to medical invoicing.
Many newly established private medical practices assume the invoicing – the “accounts bit” – is just as easy as marketing.
It will sort itself out in the end. If it doesn’t they ask a colleague how they do it.
Once again it assumes the colleague is managing his billing correctly.
Sadly he may not be.
The paradox, therefore, is that many consultant surgeons when they start out, make the same mistake as I did with my IT requirements when I started.
Two weeks and a few hundred YouTube videos later, I bit the bullet and called someone who DID know.
It cost me £150 but within ONE day I had all the systems up, running and working very efficiently.
The old adage of “if you think hiring a professional is expensive, try hiring an amateur” springs to mind.
Yet many private surgeons, by attempting to manage their own medical invoicing or asking their medical secretary to do the billing to an expert standard, make precisely the same mistake.
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I took part in a Virtual medical conference recently and one of the speakers – a well-established consultant surgeon and an incredibly safe pair of hands – stated during his presentation that a private surgeon could not charge for inpatient care.
He may well be a safe pair of hands but on that point he was wrong.
After the conference, I had a word and said he was incorrect. It IS possible to charge for inpatient care.
I couldn’t help but suggest to him that the mere fact there was a separate code for inpatient care indicated it could be charged.
Obviously, it may well depend on the insurance company concerned. In principle, however, it is possible to charge. I knew I was right because I’d actually charged for inpatient care for an MHM client a few weeks earlier. And the invoice had been paid.
But he wouldn’t budge.
He was right.
I was wrong.
Skip forward a few weeks and I received an email from my consultant surgeon friend confirming that I had been right all along and he had been wrong.
Why is it sad that I had been right?
Because my consultant surgeon friend has been in private practice for well over a decade and he’d NEVER charged for inpatient care.
More significantly though, my friend had not checked each month what could and could not be charged for.
That also begged the question if the fees he was charging had been checked with the same frequency too. He hadn’t so as a favour I checked for him.
The good news is that only 3 of his fees had altered.
The bad news is that one of them had gone up £107 five months earlier yet he was charging the old and lower fee.
Thus it is important not only does a Private Consultant Surgeon need to establish what he can or can’t charge for, it is just as important to check HOW MUCH you can charge for!
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A group of surgeons I know is having problems getting paid by insurance companies.
Not just an individual insurance company but all insurance companies.
The practice manager claimed there were many invoices unpaid by insurance companies 3 months after the consultation or episode date.
This was all the fault of the insurance companies who simply do not want to pay.
I found this odd as in my experience ALL the insurance companies I deal with pay well before 3 months have elapsed.
The practice manager therefore altered the patient’s terms and conditions to read “patients will be asked to pay anything not settled after three months”.
This is, in his words “a long stop” and would prevent the issue arising.
I’m not convinced however putting such a plaster over the wound is the correct action to take.
I’m definitely not convinced a “long stop” will prevent the problem because it will allow the invoices to become three months old and then do something about them.
I raised the following two points with the consultants and their Practice Manager:
It’s this second point that is the more relevant of the two.
Insurance companies are NOT the enemy.
Of course, I disagree with many of their fee reductions.
I also disagree when they decree certain multi procedures are now deemed to be part and parcel of each other.
The reason for my disagreement is obvious. I’m here to get the maximum amount of revenue for my clients.
Anything that reduces such revenue is not good.
Nonetheless, insurance companies should not be treated as if they are the enemy.
Insurance companies WILL settle a claim within 3 months. I can honestly say I don’t have a single invoice for one of my clients sent to an insurance company still unpaid after three months.
So why are the group of surgeons referred to earlier having problems and introducing the “three-month” rule?
Without even drilling too far down into how and when the surgeons were invoicing, I can tell you the probable cause and why they subsequently feel the rule is necessary.
That is why the invoices are not being paid earlier than the consultants are currently experiencing.
It is all about getting it right the first time.
First time means having a clinic list or a theatre list invoiced promptly with all the details required by the insurance company appearing correctly on the invoice.
Putting the effort in upfront always generates the best results. It may be tiresome and it may be an inconvenience to have to stop, make a phone call so you DO have the correct details but it pays in the long run.
Its also all about 30 days after the invoice has been transmitted to an insurance company if it is still unpaid, getting them on the phone and asking if there is a problem.
If there is, it gets sorted immediately.
In other words, the invoice is not allowed to be dated more than three months from the episode or consultation date.
Consider it this way.
If you invoice quickly and invoice correctly, the number of potential issues which may delay payment reduces considerably.
You simply must make it easy for a private medical insurance company to deal with your invoices. I actually said that to a consultant surgeon recently who wasn’t sure he agreed until I asked him if he liked money or not?
Obviously, he said he did.
Therefore, my statement was correct.
As regards the consultants who have now introduced the “three-month rule” the rule itself should be entirely unnecessary.
The cause of the problem should be examined and steps are taken to prevent the invoices from becoming more than three months old.
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It is common in my world to be presented with a number of unpaid invoices. The remit is to go get paid for them. That I can do.
If they were raised in the first place that is.
If they have NOT been raised it is much more difficult.
I’ve done it many times. It’s not without its difficulties though.
Self-funding patients normally express amazement that they haven’t been invoiced.
More than a few have put forward the view they thought they would have been invoiced ages ago.
Some have even said they’ve called the consultant surgeon’s secretary to ask where the invoice was and still nothing has arrived.
There is a very simple remedy to this problem.
Send the invoice.
What is much more problematic is the same issue with a private medical insurance company.
This is especially true where, as part of the consultant’s recognition criteria, the insurance company insist all invoices are submitted within 6 months of the episode date.
It matters not one jot whether the episode was surgical or a consultation.
The invoice must be submitted within 6 months of the date.
This is precisely the situation I faced late last year when reviewing the billing process of a northeast based ENT surgeon.
She had just over £4,250 worth of invoices for a single insurance company that had NOT been invoiced.
They were all way over six months old.
Worse still they added up to just over £4,250.
The wrong solution to this is to ask the insurance – politely or forcefully – to accept the invoices even though they are so “old”.
Most likely the private medical insurance company won’t agree to even look at them.
It is irrelevant to blame the insurance company.
A complete waste of time.
The correct solution is to consider HOW this situation had been allowed to happen.
In other words, be much more concerned there is not another £4,250 worth of surgical episode or consultation that hasn’t been invoiced. Hopefully, the value will be less but you need to check.
In most cases, there will be uninvoiced outpatient appointments. Sometimes entire surgical procedures have not been invoiced. In all cases, you need to find out.
You should also make sure a robust process is in place to prevent this from happening again. How?
The simplest of daily or weekly routines. The sanity check.
Using one of my current clients as an example, I know he holds two outpatient clinics per week and is in theatre once a week.
Therefore I should see two clinic lists and a theatre list every week.
If I don’t, I call his secretary.
Sometimes, I’ve only received one clinic list because there was only one clinic. Other times though, there were TWO clinics but she has forgotten to send me the 2nd clinic list.
Sometimes he hasn’t returned the clinic list.
The important point is that we know about it and make sure the discrepancy is sorted.
A very simple sanity check will prevent a build-up of uninvoiced appointments or surgical episodes. But do not think this is a “should” check.
hen each week, ALL MHM client’s get a spreadsheet. ONE document. All they have to do is check, the clinics have been invoiced. Surgical episodes are on there too.
This is very much a “MUST” check.
If you don’t, it is so easy to end up with £4,250 worth or surgical episodes or outpatient appointments that you can charge for but will almost certainly be refused for payment by the insurance company.
Then you may have to contact your patient and explain due to your own poor administration the patient must settle your bill.
I have no issue doing this even for we are where we are. I have to say in most cases the patient is not at all impressed!
It’s so much easier not to put yourself in the position in the first place by performing a sanity check each week.
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Ever thought what is the most often quoted reason for non-payment by a patient of an excess?
The same reason is quoted over and over again. It’s not “I haven’t got the money”. It’s not “I didn’t realise it was so much, Not even “The invoice must have got lost in the post”.
“I’ve paid it because when I registered at the Private Hospital, they took a swipe of my debit (or credit] card and the fees are taken from that”
That is often quoted to me. Twice last evening in fact.
Why is it always being quoted and should you be suspicious when it’s said to you?
In answer to the first question, it’s because the patient assumes the bill for your professional services will be “sorted” by the hospital.
They genuinely don’t realise that the transaction is between them and you as the Consultant.
Clearly, the above statement may not be applicable if the patient has purchased a “package” with the Private Hospital.
In answer to the second part, you should not be suspicious.
This is not to suggest the fault lies with the reception staff at the private hospital in any way.
Recently I went with my own partner to a private hospital. As she registered, it was very clearly explained that her debit card covered only the hospital fees if there were any.
There was even a sign up to that effect on the wall in front of us.
So my partner, as with all private patients, should realise what is covered by the swipe of their debit or credit card.
Yet a few weeks’ later when the invoice arrived from the consultant, my partner said to me something was wrong, as the Hospital had taken a swipe of her card when she attended the consultation.
I explained most likely WHY she had received an invoice from the consultant.
She, nonetheless, insisted that was wrong because her debit card had been swiped by the hospital.
This despite it being explained when she registered what her debit card would and would not cover.
Quite rightly, she called the consultant’s secretary (not an MHM client by the way!) who explained the situation and payment was made by debit card immediately.
It does demonstrate, however, the most often quoted reason why payment for an excess invoice has not been made.
“Can’t be right – the hospital took a swipe of my debit card when I registered”
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I’m used to insurance companies declining to pay a consultation charge within 10 days of surgery.
It happens all the time.
It’s the very reason before I invoice consultations within 10 days of treatment, I ask if the consultation was “routine”. Or are there additional medical reasons.
It is only the consultant surgeon who knows the answer.
If routine, a post-surgical follow-up within 10 days, might not get paid.
If on the other hand there are medical reasons, then it should be.
But what do you do?
It is best to call the insurance company.
Tell them you are submitting an invoice.
Then provide evidence WHY the consultation was necessary.
Nine out of ten times the consultant will get paid.
After all the insurance company is NOT the enemy.
If you explain why you have taken a particular action, you are more likely to get a positive response.
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Flip the question on its head.
Would you pass over your debit card details without knowing how much is going to be charged to it?
99.9% of people would say NO.
That’s today’s blog over then.
Or is it?
Because how do you know how much you can charge anyway?
In the case of self-funders, you can charge whatever you want.
Contrary to popular belief there is nothing to force you to charge as little or as much as you want.
Whether you’ll get paid as much as you want is a different matter for the self-funder has a choice.
He or she can either agree to pay the fee you quote or they can decide not to.
It’s that simple.
So, consider the following. You are a GI Surgeon and want to charge £250 for an initial consultation. But your colleague GI Surgeon down the road only charges £150.
Which is the right amount?
They both are.
It’s up to the patient which one they accept.
I’ve actually known some patients pay a higher fee because a particular consultant saw their neighbour last year and “he was lovely”.
Conversely, I’ve also known as patient decline to go see a surgeon because they said the fee was too high compared to those of another surgeon.
The original question however remains. Should you publish your fees?
In the case of self-funders, you should.
In the case of insured patients, you should state – or publish – that your fees will be in line with those stated by the patient’s insurance company.
I once debated this point with a consultant surgeon who forcefully stated it was wrong to publish fees.
Because, in his view, it might put the patients off.
That seriously worried me.
More specifically, the thinking behind it worried me.
If your patient isn’t told how much the fee is before the consultation and then decides, realises or even claims they can’t afford that much what position does that leave you in? Not a very nice one in my view.
Patients do not, however, base the decision to see a certain consultant only on price.
There are a whole host of reasons why they chose to see one private consultant surgeon over another. Recommendation. Geography. On-Line reviews. They are just three of many different reasons. An additional reason is of course cost.
But it’s not the only reason.
Therefore, tell your patients how much you charge.
After all, would you buy something without knowing how much it cost?
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MHM Ltd is a virtual business.
I’m not physically based in my client’s offices. In some cases, I’m hundreds of miles away so I can’t walk down the corridor and tap on a door to speak with a client.
Instead, we communicate by email. We also use a really old fashioned device called a telephone and actually speak to each other. Most of the time that is good enough because normally, as a consultant surgeon, my client is either with a patient or in theatre.
So I can’t exactly knock on the door anyway.
Simple. I offer to go meet my clients and have a face to face meeting with them.
It’s important for both the consultant and I this happens.
Because over a coffee or lunch you can talk through any strategic decisions that have or are coming up.
More important than that though, you actually get to know how the client feels.
For example: am I delivering what they expect of me?
How do they feel about the service for which they are paying?
Are there any areas where the client is expecting more or sometimes fewer results?
It gives me a chance to ask the questions and listen to what is being said. And it gives me the chance to respond.
It’s worth it just to listen. And listen intently.
Not with a view to interrupting but with a view to fully understanding what the client is thinking and saying. And why.
It would be very easy for me to only send reports by email to a client and ask for comments.
I do that every week anyway and sometimes the client responds with queries.
Most of the time, he or she doesn’t.
The quarterly meetings (sometimes only twice a year with some clients) makes it much easier to produce excellent results for my client.
There is no doubt about it the last 18 months or so of pandemic has change the way we work. No longer could I go see a client face to face.
I had to use Zoom instead.
At first I was really against Zoom. But – and I freely admit it – I was wrong. Zoom is a very powerful addition to MHM; it means I don’t necessarily have to be out the office all day to see ONE client.
Indeed I can hold 3 or 4 Zoom catch ups in one day and understand better the differing aims of different clients.
For example, I have one client who does not want an excess payment chased from an elderly patient under any circumstances.
Excess payments for all other clients are to be processed every week as standard.
He mentioned this to me at the first meeting we held after I started working for him – 3 months after I started working for him!
Another client isn’t bothered about the age of the patient and wants excess amounts chased just as soon as possible.
A third client likes to hear which patients have an excess, how much and then decide if they can be chased.
I don’t mind which.
I should though because the more the client gets paid, the more I can charge the client.
But its the client’s business and not mine.
Yet all three examples were only identified because, even though I’m a virtual business, I went to meet the client. I listened to precisely what the client wanted and then did it. Even then there are items which require clarification and sometimes email is not the best medium to use.
Modern technology is great.
It really is. I can both send and receive so much data it is untrue.
I can check a fee online in a matter of seconds (I guess it does help that I’ve got access to all the insurance company fee structures though)
Weekly reports are sent to clients without breaking into a sweat even.
Yet all these to me are support roles for nothing ever will or should even match the usefulness of actually meeting a client.
You cannot get the same level of understanding from email. You may get close after speaking on the telephone but in my view, you can’t as a virtual business beat actually talking face to face with a client.
Told you I was a virtual cheater.
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