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 customary and reasonable fees and anyway, you are risking your recognition with us.
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.
No argument from me on that 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 cost 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.
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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.
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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!
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Yes you can but only with the insurance companies permission!
This question arose from a group of consultants who referred patients to each other but always seemed to have problems in getting the invoice paid. Following a conversation with the insurance companies who had received the invoices the cause of the issue became very clear.
The consultants assumed that the pre-authorisation confirmed the patient could attend a clinic with any consultant. This is not the case.
Pre-authorisation is usually against a specific consultant.
If you follow the process the patient is normally referred to a specific consultant by their GP. Alternatively of course the patient may contact their insurance company and the insurance company refers them to a specific consultant. In either case a specific consultant is involved. If the consultant them refers that patient on to a colleague for whatsoever reason, it is unsafe to assume the pre-authorisation for the second consultant will stand. It may not.
What do you do?
In a perfect world the patient should have already contacted their insurance company and asked if the pre-authorisation can be transferred to the second consultant. Normally this is not a problem. But what do you do when the patient hasn’t contacted their insurance company and you are ready to invoice.
The only sensible thing to do is to speak to the insurance company concerned and explain why. In other words, the insurance company up to the point they are notified of the appearance of a second consultant, is blissfully unaware of his/her involvement with the patient. Consequently when they receive an invoice from a consultant not recorded against the patient they quite naturally be confused and could either delay payment of the invoice or worse, and very easily decline, the invoice. If this happens you will have no choice but to sort it out anyway.
It makes much more sense therefore if you do need to refer a patient to a colleague or a patient has been referred to you by a colleague to make sure the patient’s insurance company is aware of what is happening. On the occasion(s) I’ve had to do this, it has resulted in either the issue of a new pre-authorisation against the second consultant or an amendment to the already existing pre-authorisation.
Insurance companies are NOT, as I’ve repeatedly said in numerous articles, the enemy. Nevertheless it is unreasonable to expect them just to pay out against an invoice from a consultant if they receive it from a completely different consultant to the one the expected.
You can transfer have a pre-authorisation transferred to a colleague but speak to the patient’s insurance company first please.
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Take, for example, a patient who requires an injection which may be performed at a consultation.
Thus you raise an invoice for, as an example, £185 [£90 for the consultation and £95 for the injection]
Upon receipt of the invoice by the patient’s insurance company, the value is rejected. You CAN’T charge both for a consultation and an injection on the same invoice on the same day.
You can charge for one or the other but not both.
So you are paid £90 for the injection only.
What is interesting is that the immediate reaction from some consultants could well be to charge just for the injection.
That said, its already been suggested that the alternative and better way would be to have the patient attend an outpatient consultation on, for example, March 10th and then attend for the injection on March 25th.
See the patient twice in other words.
In such case the consultant CAN charge for both.
Not sure that’s in the patient’s best interests though but if the aim is to max revenue it is certainly in the best interests of the consultant.
Right up to the point the insurance company finds out.
Where it gets really tricky, is that some insurance companies WILL let you charge for a consultation and an injection at the same time.
Others will let you charge for some injections at consultation but not all injections.
Some, as mentioned, will not allow a charge for consultation and injection regardless if they happen at the same event.
And don’t forget not only do different insurance providers pay different rates for consultations.
They also pay different rates for the injection too.
Unless you check each consultation and injection episode with the insurance company concerned, you will be!
More likely you will actually undercharge at some point in time.
For example: if the insurance company DOES allow a fee for consultation and injection if you charge only for one sooner or later?
You’ll be out of pocket.
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In response to my recent blog about “gap” invoices being increasingly used to mitigate fee reduction(s) imposed on consultant surgeons, many emailed me and disagreed.
It is of no surprise the vast majority who disagreed work for insurance companies.
Some were quite vocal in the dislike of “gap” invoices.
They were of the opinion cost extraction was the ONLY way to reduce the cost of premiums.
That alone would make private health insurance more attractive.
Faced with a smaller number of potential or existing policyholders, insurance companies have sought to make the offering more attractive by making it cheaper.
But is cost extraction really the only way to make private medical insurance more attractive?
The implication of such a view, confirms the belief that price is the single factor when a patient takes out insurance.
GAP invoices, being diametrically opposed to that aim, should be resisted.
However, are patients really that fixated by cost?
Or are there other factors they consider?
Some patients are happy to pay Gap invoices. That suggests the cost is not the only factor.
Some are completely unaware of the fee reductions being imposed on their consultant.
So are they really that concerned with the cost?
To a certain extent of course they are.
All patients looking for a package with a private hospital, for example, will be price conscious.
However, that may not be the overriding factor.
Whilst they will certainly be looking for a value for money, it is more likely the perceived value of the package is more of a driver than just the cost.
Deeply involved in the perceived value is the reason the patient wants to be seen privately in the first place.
The prime reason a patient takes out private insurance is that they wish to be seen as quickly as possible, as conveniently as possible and by the consultant they want.
Yet insurance companies seem almost fixated with taking cost out of the private insurance market.
Seldom do they seem to be interested in what else the patient is seeking?
Seldom do they emphasize that a patient with medical insurance can be seen quicker and more conveniently.
Private health care is deemed to be expensive.
Whether it is or not is actually secondary.
What is more relevant is the perception it is.
So the insurance companies react by trying to take cost out. They begin a race to the lowest fee or to the bottom if you will. In doing so they sometimes shifting the emphasis away what the patient really wants.
To be seen not only at a reasonable cost but as quickly and conveniently as possible.
Keep reducing fees and sooner or later the fees will be so low the private consultant can no longer make a reasonable return.
Add in the fact there are fewer people who have private medical insurance now than at any time since the early 90s – and consistently reducing costs in search of a smaller pool of potential patients creates almost a perfect storm.
All of my clients have substantial NHS obligations which, incidentally, they perform to exactly the same skill level as their private work.
They are hard-wired to perform both in the best possible way.
So why does an NHS patient ask an MHM client if the consultant can see them privately?
By no means does that suggest a patient will pay any price to see their consultant of choice.
They want to see their consultant of choice and the most convenient time to themselves.
They do not, for whatsoever reason, want to wait
So why is it that insurance companies concentrate so much on taking cost out of the private healthcare offering, whilst almost failing to point out that private medical insurance offers rapid convenient access to a high level of facilities and a choice of whom the patient may see.
Doesn’t the existence and acceptance of GAP invoices, actually suggest that patients are prepared to pay more and not less to see a consultant as soon as they possibly can and where they wish?
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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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Two codes AB1234 £619.00 and XX2468. £124.50. Total £743.50.
It came, as somewhat of a shock to be told therefore the amount being paid to the MHM client was only £24. How can this be???
Basically, because someone at the insurance company deducted a £100 excess but by mistake recorded the AB1234 as excess also.
So instead of being paid £743.50 less £100 excess i.e. £643.50 the MHM client was out of pocket by another £619.50.
As a result, a phone call to the insurance company followed and the insurance company accepted they made a mistake. In the real world, insurance companies do make mistakes.
Took 30 minutes to sort it all out but think about it. That 30 minutes mean you are getting paid what you are entitled to.
Are you confident your fees are being paid correctly and mistakes aren’t being made?
How do you know? Have you checked?
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If you get the basics right many problems with getting paid aren’t allowed to happen. The basics mean the absolute minimum and mandatory requirements in order to present an account for your services. The basics are as follows:
Patient’s full name
Patient’s full address
Patient’s post code
Patient’s date of birth
Policy number of the insurance company concerned
Pre-authorisation number issued by the insurance company
Correct CCSD code
But it doesn’t stop there.
Your invoice should always have on it:
Your name and address
Your provider number
A unique invoice number
The date of the invoice
The date of the treatment / consultation
The right CCSD code
14 points. But if you don’t get all 14 on your invoices you make it harder for the insurance company to pay you!
If anybody wants a blank invoice that does satisfy ALL the above, go to the freebies tab on this website! If you are billing electronically – and you should be – you’ll still need the vast majority of the 14 points.
But the proof of the pudding is very much in the eating. Have a guess at what are the TWO major reasons an insurnace company does NOT pay your invoice?
1. you haven’t sent one (crazy but true)
2. you haven’t included the right information.
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An MHM client held one of his twice-weekly outpatient clinics recently. Nine patients; so there should be NINE invoices.
Except there are only EIGHT?
Quick look at the list indicates one of the patients is designated as inclusive care; no invoice required. But hang on a second, an invoice was raised for a surgical episode recently for this very patient and sent to an insurance company for payment. Indeed its been passed for payment already.
How can the follow up be deemed inclusive care if the surgical episode was chargeable to an insurance company? Generally speaking, it can’t.
Simple explanation. The patient had been incorrectly designated as inclusive care for this clinic. Once the error is corrected, there are NINE invoices. Happy days. After all its only one episode
Make that mistake only once a week for a single month and you potentially loose over £500.
And that is why MHM checks the clinic list is right each time and every time.
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A shortened version of a recent conversation with a well established private consultant surgeon.
Very recently one of the major PMI players announced a further reduction in payable fees. Definitely applicable to newly recognised consultants in January 2015, the fee reduction does not apply to those recognised previously. Ot at least it didn’t.
But it does now.
The immediate retort from another very well established MHM client was to pass any reduction on to the patient. That’s all well and good but not if she is fee assured with the insurance company concerned. I actually checked just to be sure. Yep; if a fee reduction is passed on to a patient by a fee assured consultant, the consultants recognition may be put at risk.
None of the above means MHM agrees with insurance companies reducing fees – even though market forces may on occasion be the root cause of such reduction. By all means argue with the insurance company. And I already am.
But…don’t rely solely on that argument and assume the argument fees should not be reduced will be successful. It might. There again it might not.
Instead make sure you are charging the very maximum you can. Make sure you are charging for everything you do. If the surgery takes twice as long as expected, request an uplift fee. If a double consultation is required, charge for a double consultation. Its not as difficult as you may think it is.
And don’t forget to do a sanity check each month. If you think a 20% reduction in fees is bad, consider the 100% reduction if you fail to charge an entire consultation.
Whilst the question of where fees will go will be considered in future blogs, its important before even thinking about your fees to make absolutely sure you are charging the right fee already. You’d be surprised how many aren’t!!!!
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One colleague of a current MHM client called me and said he wanted to charge more for his services. First item on the agenda was to check what is being charged now. I offered to construct an MHM fee checker for him, amongst the items for consideration was CCSD codes W0300 and W0310.
As luck would have it the same insurance company was being used with the fees calculated as W0300 £745 and W0310 £1,165. Fine. Due to a human error, the fee for the W0310 had been checked using the code W0300 i.e. he was using the same fee for both codes.
Thus the MHM fee checker confirmed the surgical fee for W0310 was £420 higher than that to which he was currently charging.
My MHM fee checker is a very useful tool. I’ve blogged about checking fees frequently and the initial version of the MHM fee checker used to review potential clients fees is free if you email me too!
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This particular blog is NOT concerned with the general question of an uplift of all fees. Nor does it relate to the question of if fees (outpatient or surgical) are high enough or not.
This blog is concerned with how you request a fee uplift. It assumes, for example, that as a private consultant surgeon you wish on a specific case basis to uplift your fee.
For example. Very recently an MHM client (his/her specialism is not relevant) found himself in the position of having to do more in theatre for the patient than he anticipated. Indeed the surgery took almost twice as long. The immediate reaction of a surgeon in such a situation might be to simply double the fee eg £500 standard fee but surgery took twice as long therefore fee should now be £1,000. So send an invoice to the insurance company for £1,000
But it absolutely is NOT as simple as that.
Almost certainly the insurance company will NOT pay the invoice. If lucky the surgeon may get paid £500; most likely the insurance company will call and ask why the increase. Even after a conversation however they won’t just pay the £1,000 invoice.
The correct way to increase a fee is BEFORE the invoice is raised, contact the insurance company and advise you will be submitting a request for a fee uplift. The insurance company will require a justification from the surgeon as to why he/she feels the fee should be uplifted. In other words they will require sight of, for example, theatre notes. A letter from the surgeon explaining why the procedure was more complicated than normal helps too.
Only then should the invoice be submitted. In other words when the insurance company receive the invoice they have already been told WHY the invoice is for a higher value than normal. They can also see a rational and reasonable reason why the request has been made. This does not mean they will accept it. It does mean the request will be considered from a more favourable position.
But don’t just double the fee if the surgical episode took twice as long even if you have followed the MHM recommended course of action.
In the case of the MHM client referred to earlier, we contacted the insurance company on his behalf. We requested a 50% uplift in fee and advised full correspondence in support of the request was en route to them too. Only then did we submit the invoice (electronically as it happens)
The happy result was later that month (May 2015 in fact) we were advised the uplift fee had been approved and our client would receive full payment.
Instead of £1,025 he received £1,537.50
feel free to email comments to:
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Some insurance companies decline to accept invoices that are sent more than six months after the consultation or surgical episode. Fair enough, they should have been invoiced.
A statement was received today from a certain insurance company containing an entry reclaiming £620 paid to an MHM client in December 2013. Whilst that was before MHM started managing the client’s medical invoicing, a phone call to the insurance company was made anyway. All part of the service. 20 minutes later the insurance company concerned confirmed the payment of £620 had NOT in fact been made to the client in December 2013!
In other words, they were totally wrong to deduct money from the MHM client. The insurance company is paying back to the MHM client the £620 at the end of the month. We’ve just saved the client £620 – result.
Hang on a second. This particular insurance company does indeed decline invoices over six months old. Yet it makes deductions from an MHM client going back not months but years. And the deduction was wrong anyway.
Moral of the story?
ALWAYS check the payment remittances from an insurance company. 99% are correct but that last 1% can be worth hundred of £’s!
How many of you have had this happen to you? More importantly how many of you realise it has happened?
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It actually happened too.
Consider a CCSD code for a follow up consultation = 20310. Now consider the CCSD code for a ECG = 20110.
A consultant surgeon couldn’t understand why he was not getting paid the right values for his follow up consultations i.e. £150. Instead, he was getting either £72 from one insurance company, £96 from a second or zero a third. The reason was clear when MHM investigated.
It was because some of the invoices for his follow-ups consultations had been coded as 20110 [ECG reporting] and not 20310 [follow up consultation]
That one digit incorrectly quoted was making all the difference.
Insurance companies were seeing 20110; some were querying the code when the patient hadn’t had an ECG but others were happily paying the fee for the 20110. The third insurance company did not cover 20110 ECG as part of their patient offering and thus declined to pay anything.
When numbers were audited the average discrepancy was £65. When all numbers were in, the number of errors equaled 11. And thus the client was out of pocket by approximately £725.
The consultant concerned was not happy, especially when his work did not require an ECG anyway. Thus one day’s analysis and the consultant now receives the right fee – because the right code and fee are being used.
Even getting ONE digit wrong can cost £725.
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Recently a family member in conjunction with his/her GP decided an appointment with a private consultant was necessary.
As the family member had private medical insurance through his/her employer, a phone call was made to the consultant suggested by the GP.
It turned out although not an MHM client, the consultant practice manager and I are old friends. So I made the call myself. An appointment was subsequently made.
Came as a surprise the next day, for my family member to announce the insurance company had called suggesting another consultant.
My family member asked why and was told the second consultant didn’t charge as much as the one he/she originally wanted to see.
Not a good thing to say. My family member insisted – and had to insist – on seeing the consultation of his/her choice.
I quickly found out how much the second consultant charged for an initial appointment. It was indeed lower.
Nonetheless, the appointment with the first choice consultant happened.
Two weeks later a letter arrived from my family member’s insurance company stating the consultant had been paid. There but was however a shortfall. The 1st consultant’s fee was higher than that of the second consultant. My family member was required to pay the difference.
The fact that my practice manager friend is pulling her hair out at the moment with the increases in shortfalls is not the point.
The point and the stark reality is that the insurance company were using finance as a criterion upon which to base the decision which consultant one of their policyholders (my family member) went to see.
And that, I’m sorry, is NOT right.
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