Most consultants when they first start a private practice, consider how best they can set their fees.
In the case of self-funders, there is nothing to stop you charging any consultation fee you like.
Save of course if there are other consultants in your area then their fees will influence that which you charge.
Effectively it is up to the patient whether they chose to accept that fee or not.
In reality, in the case of an insured patient, it is not the consultant who sets fees.
It is the patient’s insurance company.
Consideration of fees for an insured patient should be viewed from two distinct areas:
1: Consultation fees
2: Surgical Fees
Consultation fees (for both initial and follow up) will be agreed at the point of recognition by the respective insurance companies of the medical professional e.g. consultant surgeon, anesthetist, etc.
The insurance company with whom your patient is insured will always set surgical fees.
You may feel the fee is too low and therefore try to charge more.
Almost certainly your invoice WILL be rejected.
Keep sending invoices in for fees greater than that allowed by a particular insurance company and you run the risk of being de-recognised.
It’s not a good idea to be in such a position.
Whether it is right or wrong for insurance companies to hold such power over the setting of surgical fees is for another article.
I have very firm views on it but at this point, the stark reality is that the insurance companies do hold most of the cards.
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I spent some time yesterday looking at the invoicing of a consultant surgeon.
I noticed that the invoices for initial consultations going out to one particular insurance company were being charged at exactly the same fee as for follow-up consultations i.e. £125 each.
Instead, they should be £175 for initial and £125 for a follow-up.
So… £50 multiplied by the number of errors spotted so far over the first month I’ve checked (9) = £450!
The bad news is that this has been happening for, so far as I can tell at the moment, for at least the last four months.
Potentially, £1,800 worth!
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Top up (or GAP) invoices = asking the patient to agree to pay the difference between a consultant’s fee and the fee an insurance company is prepared to pay.
The discussion concerning them seems to take place more in whispers than anything else.
And sometimes they are even deemed to be almost a taboo subject because they don’t exist.
But they do.
So, and for the record:
I have no problem issuing them on behalf of my clients.
Why and when?
Consider the case of a real consultant surgeon whose patient is quite happy to pay, for example, £852 for a surgical episode.
But the patient is insured with XYZ Insurance.
XYZ will only pay a “customary and reasonable fee” of £639.
The fee was £852 but due to “market conditions” XYZ has reduced it by 25%.
Thus the consultant may now as part of his recognition protocol only charge £639.
Most consultants actually perform the same procedure throughout the month.
Empirical evidence using MHM clients confirms they all perform, in their own specialism obviously, the same code(s) on average 5 times a month.
If that code happens to be the one reduced by £213 each time, the reduction in revenue is over £1,000 each month.
In the original scenario though, the patient has chosen to see that particular consultant.
His/her decision has zero to do with fees.
That is the consultant the patient has chosen.
If the patient is advised the fee for their procedure is £852 but their insurance company will only pay £639 towards it and then if they – the patient – is asked beforehand to pay the difference and agrees, where is the problem?
Ah no, say the insurance company, you can’t do that for that is above our stated fee schedule so you are risking your recognition with us if you do.
This article is not about if they are right to potentially withdraw recognition if fees are not adhered to.
Neither is it about whether XYZ Insurance is right to reduce the fee.
The first thing consultants will all do is be deeply unhappy about the reduction.
The second thing they will do is attempt to mitigate the loss somehow or another.
And the second point is the more relevant one.
Many times I hear from insurance companies the market is contracting and cost has to be taken out to make the private medical insurance offering more attractive.
But why is the cost reduction, or so it appears, being continually directed at the consultants?
Yes, I am aware that certain fees have gone up but overall fees have come down.
I’m equally opposed to those consultants who insist on ignoring insurance companies’ fee structures for every single procedure and/or episode.
I’m also very focused on taking costs out of any business so I can see where the insurance companies are coming from.
But not at the expense of continually reducing a consultant’s fee and thereby reducing his profit continually AND the patient’s right to a choice.
Top Up or Gap invoices are a reaction to consultants continually seeing their fees being eroded.
I haven’t said I completely agree with them for they should be unnecessary.
What I am saying is that I understand why I’m being asked to produce them and when.
Consider an actual quote to me recently from a very well established consultant surgeon.
An orthopod who has been in private practice for over 10 years:
That, perhaps, sums up precisely why some MHM clients are asking me to produce Top Up or GAP invoices.
pete@medicalhealthcaremanagement.co.uk
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I hear this quite often.
Normally from prospective clients who call and want their fees reviewed.
They claim they have a colleague who gets £250 from BUPA or £350 from AXA.
But they have only been offered £136 from BUPA and £175 from AXA.
The first question I ask is what specialism are they in?
The second is what specialism is their colleague in?
This is very much a loaded question because I already know the answer to the first part.
BUPA paying £250 for an initial consultation and £350 for an initial consultation, tells me the colleague is a mental health specialist.
Then, and it happened last week, the caller tells me they themselves are an ENT consultant.
Et Viola!
There is the answer.
BUPA and AXA pay more for a mental health specialist than they do for an ENT consultant or a gynecologist.
I do have a rye smile on my face when the caller points out, they are just as qualified as a gynecologist or as an ENT.
For what it’s worth I agree.
But the reality is, BUPA and AXA deem mental health specialists to be worth more.
The usual argument is that they spend longer with their patients. I have no idea if that’s correct or not.
But what I do know is those are the fee levels.
Arguing with either insurance company that the rules are misguided is, frankly, misguided.
pete@medicalhealthcaremanagement.co.uk
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I was at a 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, i
t 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!
pete@medicalhalthcaremanagement.co.uk
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I spent some time yesterday looking at the invoicing of a consultant surgeon.
I noticed that the invoices for initial consultations going out to one particular insurance company were being charged at exactly the same fee as for follow-up consultations i.e. £125 each.
Instead, they should be £175 for initial and £125 for a follow-up.
So… £50 multiplied by the number of errors spotted so far over the first month I’ve checked (9) = £450!
The bad news is that this has been happening for, so far as I can tell at the moment, for at least the last four months.
Potentially, £1,800 worth!
It is easy to lose 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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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 the 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.
pete@medicalhealthcaremanagement.co.uk
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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 was subsequently asked to handle the medical billing side. In order to do so, we need to know how much consultation fees were. The medical professional, however, did not know what the consultation fees were. Thus alarm bells immediately started ringing.
Consultation fees would have agreed to and would have been detailed in the pack supplied to them by the insurance company concerned as we had advised. So we called the insurance company and quoted the newly acquired provider number.
As usual, the insurance company was keen to point put the consultant had agreed to adhere to the published fees.
It is always amusing when “fair and reasonable” is quoted to me because it depends on what the consultant thinks is “fair and reasonable”. More specifically what happens if the thinking differs between the two parties concerned. And that is precisely what happened in this example.
The insurance company deemed that £175 was a fair and reasonable fee for a consultation. The consultant had signed agreeing to £175
The medical professional deemed that £250 was a fair and reasonable fee.
And thus the consultant instructed MHM to charge a consultation at £250.
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 £175 originally agreed.
And that is precisely what did happen.
Despite the medical professional objecting strongly to a consultation fee of £175 and insisting a “fair and reasonable” fee was £250, 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 £250.
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 £250. 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 £250. 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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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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It is depressing the number of times I hear potential clients criticising 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 the 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 you may be pleasantly surprised.
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 2017 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 to 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 a theatre.
Who is driving the car?
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 in 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 to accept the fee reduction or reject the fee reduction. That I’m afraid is the reality.
pete@medicalhealthcaremanagement.co.uk
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A common mistake made by a private consultant surgeon when invoicing is undercharging for their work. This is alarming when most consultant surgeons wish to increase their fees.
This always spins off into a debate regarding private medical insurance companies being the enemy. Fees are always being reduced with the private surgeon being paid less and less. That may be true sometimes. It is not the right place to start, however.
The right place to start is to make sure you are charging the correct fee. Such fee may be less than you want of course but, many times, be more than he thought you were entitled to.
Take the example of an orthopaedic surgeon who contacted MHM to process her medical invoices recently. She thought her consultation fees were too low. That also may be correct. But that was the consultation fee the insurance company was prepared to pay.
The orthopaedic surgeon was unaware some of the insurance companies were prepared to pay a fee for minor procedures carried out at a consultation. They would pay a procedure fee together with a fee for the consultation. Whilst some insurance companies weren’t prepared to pay both fees, some were. Instead, the consultant had been charging ONLY for the minor procedure. She had not been charging for a consultation as well.
The same situation was equally applicable to a private dermatologist just as it was applicable to a GI surgeon. It is not therefore applicable solely to orthopaedic surgeons. It is applicable to many specialisms. The issue, therefore, becomes one of: am I charging the right fee?
To confirm the fee is correct a review of procedure codes and the fee for the procedure code should be undertaken. Both may then be compared against the fee structure of the private medical insurance company concerned. Each code and combination of codes must be checked against the fee schedule of the private medical insurance company. The often stated assumption that all insurance companies pay the same fee for the same procedure code should be rejected.
Take the example of a repair of the primary repair of Achilles tendon. Insurance company A pay a fee of £336 whereas insurance company B pay £405 – £69 more! The orthopaedic surgeon concerned was of the belief insurance companies paid out the same fee. She had UNDERCHARGED by £69 as a result.
To return to the original issue of charging a consultation fee alongside a fee for a minor procedure, take a look at injection into soft tissue. The same insurance company paid a fee of £108. The orthopaedic surgeon in question was unaware that a follow-up consultation could be charged in ADDITION to the fee for the injection. Another £150 on top of the £108! Thus the correct charge was not £108. It was in fact £258
To further illustrate the point a dermatologist may charge the very same insurance company, £91 for a curettage of skin or lesion. He or she may also charge a follow-up consultation fee in addition. If the follow-up consultation fee is £100 (and it is for the MHM client concerned) the fee for the WHOLE event has doubled!
Thus the most common mistake in medical invoicing is not realising that fees can and do differ between insurance companies and also that some, not all but some, private medical insurance companies will actually and quite happily pay MORE for your work than you may be aware of.
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 to 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 a 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 in 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 to accept the fee reduction or reject the fee reduction. That I’m afraid is the reality.
pete@medicalhealthcaremanagement.co.uk
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Sometimes even a consultant surgeon does not understand how valuable his time is.
All of my guys 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 with 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 long-suffering 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. My private patients are paying to see me so they must come first”
I agree with him.
Sadly 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 “Too busy to deal with that and 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 too. 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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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 from this morning (Thursday, November 16th) 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 the very next day. 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 also used. It also indicated the correct price for each and a total value for the combination involved. In other words xxx (the consultation) = £125. The yyy (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 onto 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 and that insurance company 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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That perhaps is one of the statements, I hear from private surgeons more frequently than others.
The following example, however, illustrates that despite the rejection of the fee, examination of how the fee was established confirms there is little the consultant can do about it.
The consultant surgeon concerned only recently applied to be recognised by the private medical insurance. That in itself is not too difficult a process. MHM spoke to the consultant and pointed out fees should be carefully checked when recognition was being arranged. The consultant was extremely well qualified, had held a substantial NHS post for a number of years and his/her specialism was in high demand. The private medical insurance policy was keen to offer recognition. The recognition was thus granted.
MHM was subsequently asked to handle the medical billing side of the practice. In order to do so, we need to know how much the outpatient consultation fees were. Even we can’t charge if we don’t know how much to charge. The medical professional did not, however, know what the consultation fees were. Alarm bells started ringing immediately.
Fees incidentally that they would have agreed to and would have been detailed in the pack supplied to them by the insurance company concerned. So we called the insurance company.
The insurance company, as usual, advised the consultant had agreed to their published fees.
It is always amusing when “fair and reasonable” is quoted. It depends on what the consultant thinks is “fair and reasonable” against what the insurance company thinks is “fair and reasonable”. What happens if the thinking differs between the two? And that is precisely what happened in this example.
The insurance company deemed that £100 was a fair and reasonable fee.
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 though, is the insurance company would reduce the value of the invoice down to the £100 originally agreed.
And that is precisely what happened. Despite the medical professional objecting strongly to a consultation fee of £100 and insisting a “fair and reasonable” fee was £175, the invoices were reduced in value.
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 more than £175 for a consultation. This was so because the second colleague was in a completely different specialism!
Sadly the MHM client had based their practice business plan on a consultation fee of £175. They had done so because they had asked colleagues how much they were paid. They had then 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 was never going to be won. The simple reason remained that at the point of recognition the MHM client had accepted the fees. It mattered little the client hadn’t fully understood what was being offered (despite the fees being detailed in the recognition pack sent to the client).
Sure enough, the insurance company stood firmly behind its agreement with the consultant.
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. 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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In by far the majority of cases, your patient will obtain authorisation for a consultation in advance of the actual date.
But sometimes, the patient arrives for the consultation without a pre-authorisation. First question: should you see the patient?
Of course, you should. Patient care must come first.
So what do you? How should the private surgeon handle it then? Ask the patient to ring his/her insurance company and obtain the pre-authorisation as soon as they possibly can. But….
If the consultation was on February 8th and the patient does not call the insurance company until February 15th, the patient should make sure the insurance company know when it took place. In this example, the patient did not tell the insurance company it was a week earlier.
Thus when MHM tried to invoice, it was declined. The consultation was before the date upon which the pre-authorisation was issued.
If the patient holds an insurance policy, which will not allow the backdating of a pre-authorisation you’ll have more difficulties. In this case, an invoice for the initial consultation should be sent to your patient.
The patient has incurred a liability on behalf of the insurance company. But the insurance company knows nothing about it. Ultimately the patient is liable for the consultation fee of course thus the invoice is sent to the patient.
But the insurance company knows nothing about it. Ultimately the patient is liable for the consultation fee of course thus the invoice is sent to the patient.
The patient rings up (normally quite upset) and points out they are insured and are indeed covered for consultations in their view.
Ultimately the patient is liable for the consultation fee. Thus the invoice is sent to the patient.
Numerous phone calls between the patient and the insurance company and the problem is sorted. The invoice is submitted to the insurance company and its paid in full. This time it was anyway.
It would have been paid a lot quicker IF the patient, when they made the consultation appointment, had been asked to advise their insurance company the consultation was for a specific date. When the patient arrives for the consultation it is then simply a matter of confirming with the patient, the correct
When the patient arrives for the consultation it is then simply a matter of confirming with the patient, the correct authorisation numbers have been obtained.
If this is happening to you, it’s an issue that should be addressed and prevented otherwise you may spend 15 – 30 mins just sorting this one small problem out!
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 anymore 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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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 were 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 firm behind its agreement with the consultant.
ASSUMPTION LEADS TO PROBLEMS.
The moral of this sorry tale is best summed up by the above heading. I’m not suggesting you shouldn’t challenge fees for consultations or indeed a surgical episode but don’t put yourself on the back foot by accepting fees and then challenging them afterwards. As painful as it is for the MHM client, it really is as simple as that.
Check your fees before you agree to them!
pete@medicalhealthcaremanagement.co.uk
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