Another question asked at the recent Medical Defence Union presentation.
Insurance companies use medical coding to identify and detail a medical procedure.
For example, an Orthopaedic surgeon will understand what a Multiple arthroscopic operation on the knee is. But that is an awful lot to put on an invoice every time. Plus there may be variations on such an episode.
It’s better to put the code W8500 on the invoice which will specifically identify the episode.
Most codes can be located on the CCSD website: www.ccsd.org.uk
The Clinical Coding and Schedule Development Group (CCSD) consists of the five major healthcare insurers. Aviva, AXA-PPP, BUPA, Vitality and Simply Health. Its purpose is to maintain a common standard of procedure codes. Consequently, CCSD publishes a Schedule of codes which reflect current medical practice.
However, be warned. Whilst the example above of W8500 will be recognized, a CCSD does not publish a suggested rate of remuneration.
The rate payable for each code is up to the individual insurance company concerned. As a result, the surgeon has to check with the patient’s insurance company.
A CCSD code is imperative IF a surgical episode is required. The patient will need to quote the code to his or her insurance company when pre-authorisation is being requested anyway.
Thus when an invoice is sent to the insurance company for your fees, the code should appear on the invoice. It will reconcile to that expected by the insurance company.
If alternatively, you do NOT use CCSD codes payment will be substantially delayed if made at all!
pete@medicalhealthcaremanagement.co.uk
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There are certain items that are mandatory when you call a patient’s insurance company. Such requirements are dictated by the Data Protection Act and, put simply, it’s highly unlikely without the right information you can make an inquiry regarding a patient.
In the ideal world, you will have:
The Policy Number Patients name Patient’s FULL address The POSTCODE (don’t forget it) Patient’s Date of Birth Treatment date CCSD code
The pre-authorisation number is very useful too.
But what do you do if you don’t have the policy number? If you have the patients name, full address (inc the postcode!!) and date of birth you stand an extremely high chance of the insurance company telling you the policy number. Indeed often I’ve had to speak with an insurance company to obtain the policy number.
With the above to hand, it’s not an issue. Use the opportunity to confirm or obtain the pre-authorisation reference as well though.
On a parallel note, some insurance companies will only let you raise three queries per phone call with them. Some may, if they are not too busy, do more but generally speaking three is the limit.
This despite what many think, is important for if you have say 12 to do, it’s going to take time. Especially if you are on hold for 10/15 minutes BEFORE you get through to the insurance company.
So, the very best thing to do is to make sure the clinic list has absolutely everything you need in order to invoice correctly. That way, you won’t have to contact the insurance company first. Also of course, if there is an invoice query after you’ve billed the consultation/episode you will have all the data in front of you when you DO speak to the insurance company.
Without it, you will struggle.
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I argue with medical insurance companies all the time.
Let me, however, be very specific about when and why I argue with them. I argue with them when I think they are wrong or when I think they have made a mistake.
A real example will illustrate why and when to argue with an insurance company.
MHM has a client who performs a specific test at a consultation with a patient. He has done so on more than one occasion obviously and with patients holding cover provided by all the major insurance companies, I’ve invoiced for him many, many times. Per normal MHM won’t reveal who the client is, his specialism or indeed the true value of his charges. For the purposes of this example please assume the charge is £125 for the consultation and £75 for the test.
The invoice was raised and sent electronically to the insurance company. It detailed all the correct details i.e. patient’s name, complete address, date of birth, policy number, pre-authorisation number. The correct CCSD code for both the consultation and the test were used. It also indicated the correct price for each and a total value for the combination involved. In other words xxxx (the consultation) = £125. The yyyy (test) = £75. Total value = £200.
Surprisingly, when the remittance arrived electronically from the insurance, only the consultation had been paid. A note appeared on the remittance advice stating it was not possible to charge for a consultation and that particular test at the same time.
Except, you can.
Before picking the phone up to call the insurance company concerned I first visited the insurance company’s website. The codes were correct. The fees for each code were correct. There was no indication that the combination could not be charged alongside each other whatsoever. I was pretty certain even before I’d checked that I was right but it doesn’t hurt to check. I could have been wrong. More likely it could have been that the rules had been changed.
Establishing the facts is vital when raising invoices for medical billing. Actually its true of all commercial situations but is dependant on what is deemed to be a fact. What some claim to be facts turn out to be anything but sometimes. In this case, though the facts were as I thought them to be. It was perfectly acceptable to charge the two codes together. Only then did I call the insurance company.
Having passed the normal Data Protection requirements i..e patient identifiers etc, I asked WHY this particular charge had been reduced? It was explained to me that the combination was invalid. It was unbundled as they say. Except I insist it was valid, was not unbundled and further, the insurance companies OWN website said the combination was permissible. The phone went quiet for a while and then I was told the insurance company was wrong and I was right. The £75 would immediately be paid to the consultant involved.
Despite what you may think it is not unusual for an insurance company to make a mistake, admit they have made a mistake and then rectify it straight away.
Don’t, however, call an insurance company and twist the facts. By that I mean don’t call them and say their fee isn’t right and should be much higher. That is not a fact, it is an opinion. When faced with a combination of codes that can’t be charged together do NOT separate them into two invoices one being sent on a Monday and one on a Tuesday. Don’t unbundle in other words. Insurance companies may make mistakes but they aren’t stupid.
Its very much a case of “picking your arguments” and challenging an insurance company in the right way and on the right subject.
But is also very, very much a case of noticing that the insurance company have made a mistake and asking them to rectify it. The number one statement made to me by private consultant surgeons is that fees are too low (I agree for what its worth) and that insurance companies are really, really difficult to deal with. They are not.
As regards fees, however, if you want to increase your fees the first port of call is actually to check you have a) charged the right amount to begin with and then b) making sure you ARE ACTUALLY PAID the right amount. In the example above the £75 wasn’t lost, it was paid to the medical professional concerned.
Look at it this way. His total charge was £175. If I hadn’t noticed the £75 had been deducted in error, he would have received 43% less than he was perfectly entitled to be paid!
pete@medicalhealthcaremanagement.co.uk
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A question asked at the recent presentation.
Insurance companies use medical coding to identify and detail a medical procedure. For example: if you are an Orthopaedic surgeon you will understand precisely what a Multiple arthroscopic operation on knee (including meniscectomy, chondroplasty, drilling or microfracture) is.
That is an awful lot to put on an invoice every time you produce one! Plus there may be variations on such a procedure.
The code W8500 will specifically identify the procedure. Put this code on the invoice instead.
Codes can be located on the CCSD website: www.ccsd.org.uk
The Clinical Coding and Schedule Development Group (CCSD) consists of representatives from the five major healthcare insurers.
The CCSD Group’s purpose is to maintain a common standard of procedure codes. Codes that reflect medical practice within the independent healthcare sector and are freely available.
A CCSD code is imperative IF a surgical episode is required. The patient will need to quote the code to his or her insurance company when pre-authorisation is being requested anyway.
However, be warned.
The example above of W8500 will be recognized but a CCSD code does not come with a suggested fee. The rate for each code is up to the individual insurance company concerned. You need to contact each insurance company to discover what fee they will pay for a code.
When an invoice is sent to the insurance company for your fees, the code should appear on the invoice and will reconcile to that expected by the insurance company.
If you do NOT use CCSD codes payment will be substantially delayed if made at all!
Without a CCSD code, you will not be able to invoice electronically anyway!
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One MHM client provides expert reports for actions that are publicly funded i.e. invoices are passed to the Legal Services Commission.
Scenario:
Consider there are FOUR parties to an action, all of whom are publicly funded. The first item to establish is how much is chargeable and at what rate together with what is NOT chargeable. Earlier this year (for example) the hourly rate was reduced so actions commenced before a change date becomes chargeable at one rate, those after at a lower rate. For the purposes of this example, assume the current rate is £125 per hour. So, the expert took:
4 hours to read the report 3 hours to dictate it 1 hour to proof read and amend if necessary.
Therefore it took a total of 8 hours – 8 hours @ £125 per hour = £1,000.
But there are FOUR parties to the action and therefore four completely separate invoices need to be raised for £250 each. It is not advisable to send one invoice to the lead party for two reasons: (1) you are expecting them to collect your money for you (2) you are relinquishing control of who precisely owes you your money and what’s happening with it.
That said, your invoice MUST show the number of hours for EACH separate item i.e. reading, writing etc. If an invoice just stating £250 is raised it WILL be rejected.
Consider the issue of a Court Appearance.
The number of hours at Court is also chargeable at £125 per hour. Time taken in traveling to Court is also chargeable but only at £40 per hour. Mileage is another area that causes confusion. MHM overcomes this easily. Take the postcode of the expert’s start point and the postcode of the destination and look them up on www.theaa.com or another route finder website. It doesn’t really matter which.
What is important is that the distance is based on a fixed source. This is infinitely better than just saying 90 miles for example. If the allowance per mile is, say, 40 pence, then 40 times 90 = £36.00.
Hopefully, the above gives and an indication of how to tackle how to invoice for a publicly funded report.
However… Do not consider instead of stating 4 hours to read a report, put a claim in for 7 hours in order to increase your fee because the Legal Services Commission guys are seriously switched on. They know only too well, how long a “standard” report takes to prepare. There may well be nonetheless a perfectly genuine reason why the report took longer and therefore you should say so.
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The normal item when I get asked to review a consultant’s invoicing process is the potential for weakness in the area of records on his/her part.
Sometimes, I’m presented with a carrier bag full of invoices, remittances, and receipts. My favourite though remains the cardboard box stuffed full of pieces of paper. That was the filing system. Close examination of the pieces of paper in the cardboard box suggested they were invoices. Many in fact did not have an invoice number on them. Indeed the majority did not actually have the word INVOICE printed on them either.
That can be a problem when I come to reconcile payments against such payments IF they’ve been paid at all. That is important because it’s difficult to contact an insurance company and discuss invoices for one individual patient if the invoice does not show a specific invoice number. In fact, the only way you can tell them apart is if the values are different and they are on different dates.
It’s always best to have a unique reference number on an invoice i.e. an invoice number and a date. And don’t forget to print the word INVOICE on it. At least that way, you stand a chance of knowing which ones have or have not been paid.
Then the hard part starts as you begin to look at what is or is not on the invoice and get a feel for what was likely to be paid anyway and what was likely to be rejected due to total lack of detail. Normally this is followed by a request to see clinic lists and the process of obtaining the right data off the clinic list for submission to the insurance company.
There is also an additional cost to not keeping accurate records. When it comes to tax time, its going to take a lot longer – and thereby cost much more – for your accountant to do the necessary computations. At worse you could end up paying too much tax.
All because records aren’t kept correctly. Please keep accurate records if only because it means you stand a much higher chance of being paid!
Please email me if you want details of the bare minimum records you should be keeping for invoicing purposes.
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One of the most common remarks I hear from my guys is the number of patients they see in the NHS.
They have patients queuing up to see them. Such a comment is normally followed by the opposite when discussing a private practice.
They want to see and need to see MORE patients.
This, for me, confirms the cultural difference between the public and private sector.
In the NHS, a consultant surgeon does not have to do much in order for patients to be delivered to them.
In the private sector, the opposite applies.
In the private sector a consultant surgeon, because a private practice is a business, MUST do everything he can to attract a patient. He must engage in pro-active marketing.
He must ensure it is known his practice is there.
First of all, however, he must comprehensively understand WHY a patient is choosing to go private.
It is not merely the case of a patient wanting to be seen privately because he or she has private medical insurance.
More accurately it is understanding WHY the patient has private medical insurance.
More likely it is because the private patient wishes to be seen quicker.
Even so, a consultant surgeon MUST still engage in marketing.
If the patient can be seen at the private practice quicker than at an NHS location but the patient is unaware the private practice exists then all bets are off.
Therefore a marketing plan of some description is an integral part of a private consultant surgeon’s business plan.
And therein lies the reference to the first and absolute cultural difference between an NHS practice and a private practice.
It’s a Business
A Private Practice is a business.
In an NHS practice, patients will be delivered to the consultant surgeon without him even asking.
In private practice, patients will not just be delivered. They have to be attracted to the practice or more accurately to the business.
Note the use of the word BUSINESS for a private practice is a business.
This is not the time to discuss which marketing strategies will and do work best for a private consultant surgeon.
This blog is more concerned with highlighting that due to the differences between the NHS and the private sector.
A private consultant surgeon has no choice but to have a marketing strategy.
Just as a consultant must have a robust infrastructure to support the business, it is equally as important to have a marketing strategy.
Look at it this way, if any business does not have a regular number of customers or clients (in the case of a medical practice PATIENTS) then inevitably the business will not succeed.
pete@medicalhealthcaremanagement.co.uk
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One of the most often asked questions is “how as a private consultant surgeon can I improve or increase my cash flow”.
The answer, as regards medical invoicing, is very simple to answer:
But what does that mean in reality? It means taking all the items that should be done and turn them into a MUST be done. For example, I took a phone call from a consultant’s secretary this morning who wanted a favour. She was struggling to get an invoice posted electronically. She was trying to invoice BUPA. Simple enough you may think but despite having a policy number, she could not process the invoice.
So how did it take me approximately 3 seconds to work out precisely WHY she couldn’t process the invoice?
She told me the policy number began BI-6000 etc.
That told me the policy number was not a BUPA policy number; it was a BUPA INTERNATIONAL policy number. She was trying to invoice the wrong insurance company. A quick fix to process the invoice, again online, to BUPA International and it sailed through. Sorted.
If standards had been raised to ensure that every single patient registration form had been completed correctly, this problem would not have occurred. The invoice would have been processed the same day and payment made when required. Instead, a shortcut had been attempted and the patient’s insurance company detailed incorrectly. If standards had been raised to ensure this was checked and spotted the invoice would have been immediately processed. There are no shortcuts if you want to get paid. As it happens in this case the issue was already a week old before I took the phone call.
Thus an increase in cash flow – the outcome desired by the private consultant – was not being reached.
However, if you stop to think there are two questions:
When the patient was registered, why wasn’t the check performed to ensure the right insurance company was recorded because it should have. What should have happened was the standards had been set too low. If it becomes a case of the patient MUST be asked i.e standards are raised then this specific problem is never allowed to arise.
And that’s what I mean by raising your standards.
So why is this even more crucial as we work our way toward 2018?
Because more and more private medical insurance companies are insisting invoices be submitted electronically. The issue is not one of is that the right thing for them to do or not. The real issue is that it is happening and standards must be raised to ensure you CAN invoice electronically. In other words, if you don’t have all the right details it is much, much harder to process an invoice electronically. You will instead have to re-contact the patient and get the right details.
Therefore it makes more sense to say you MUST get the details upfront and you must RAISE YOUR STANDARDS to the point of saying – the correct details MUST be obtained and checked.
I’ve even witnessed where an invoice can’t be processed because the postcode has been recorded as W01 (numeric) when it should say W01 (alpha) Incidentally.
Many times I’ve said insurance companies are not the enemy. Even if I frequently disagree – I do on a daily basis sometimes – with some of their fees plus other items they do which are seriously irritating, all insurance companies will pay a private consultant IF (and only if) ALL the details are correct. In other words, invoices must be raised to the correct standard.
If you want to increase or improve your cash flow, the very first thing to do is to raise your standards in the area of invoicing.
pete@medicalhealthcaremanagement.co.uk
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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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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.
Things Change
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 orthopaedic 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 a 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.
Different Rules
What was concerning was previously the dermatologist had not been charging for the S5210 at all. I actually asked his practise 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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A CCSD codes is used by insurance companies to identify a medical procedure.
An Orthopaedic surgeon, for example, understands what a Multiple arthroscopic operation on the knee (including meniscectomy, chondroplasty, drilling or microfracture) is.
But it’s a lot to put on an invoice every time you produce one!
Put the CCSD code W8500 on the invoice instead. It will identify that specific procedure.
So where do you find a code?
A CCSD code is found on the CCSD website: www.ccsd.org.uk
The Clinical Coding and Schedule Development Group (CCSD) consists of representatives from the five major healthcare insurers – Aviva, AXA-PPP, BUPA, Vitality and Simply Health.
The group’s main purpose is to maintain a common standard of procedure codes. The codes reflect current medical practice and are published as the CCSD Schedule.
The various insurance companies will, therefore, recognize such codes.
Whilst the example W8500 above will be recognized, it does not come with a suggested fee.
The fee payable for each code is up to the individual insurance company concerned.
To find the correct fee for the code, the insurance company concerned should be contacted.
When an invoice is then sent to the insurance company for payment, the code should appear on the invoice. Both the code and the fee will match that expected by the insurance company.
If alternatively, you do NOT use CCSD codes payment will be substantially delayed if made at all!
pete@medicalhealthcaremanagement.co.uk
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Recently I was reading an article in a business management magazine.
The article highlighted some of the challenges faced by small business owners when they start.
But it could also have been written about a consultant surgeon starting a medical practice.
The article illustrated how many small business owners attempted to start their business without assistance.
It is therefore common subsequently for the business to struggle with, for example, a lack of customers or a lack of cash.
This is normal for a consultant surgeon starting a private practice too.
It is not easy to start a private practice. There is a huge amount to be considered.
The basic rule is that if it can go wrong it will go wrong.
It happened when I formed MHM too.
Despite 35 years worth of managerial experience in running a business for various employers, I was used to ringing IT and having them install a new computer.
As a small business, ALL of that had to be done by myself. I soon realised, even though it cost, it was much better to go out and find someone who DID know what to do.
The first item in the article stated the first challenge facing a new small business is a lack of clients.
The same situation a newly established private medical practice faces too.
The second item was the lack of cash.
When I go meet a prospective client both are mentioned. Regarding the second point, the amount of cash generated by the small number of patients is nowhere near what was expected.
Yet I recollect when speaking to a colleague who specialised in marketing for consultant surgeons, most practices do not have a process in place to utilise the positive experience enjoyed by existing patients.
Their lack of new patients could be helped by using testimonials from current patients. The new practice does not have the right marketing strategies (both online and offline) to attract patients consistently.
Instead, marketing is left to drift.
My colleague is an expert at medical marketing yet she suffers from consultants believing she is too expensive to engage.
Alternatively, the new private consultant surgeon has a conversation with a colleague who has an established practice.
Hopefully, this pays dividends but it does suppose the established surgeon is maximising his own marketing efforts.
Precisely the same happens when the subject turns to medical invoicing.
Many newly established private medical practices assume the invoicing – the “accounts bit” – is just as easy as marketing.
It will sort itself out in the end. If it doesn’t they ask a colleague how they do it.
Once again it assumes the colleague is managing his billing correctly.
Sadly he may not be.
The paradox, therefore, is that many consultant surgeons when they start out, make the same mistake as I did with my IT requirements when I started.
Two weeks and a few hundred YouTube videos later, I bit the bullet and called someone who DID know.
It cost me £150 but within ONE day I had all the systems up, running and working very efficiently.
The old adage of “if you think hiring a professional is expensive, try hiring an amateur” springs to mind.
Yet many private surgeons, by attempting to manage their own medical invoicing or asking their medical secretary to do the billing to an expert standard, make precisely the same mistake.
pete@medicalhealthcaremanagement.co.uk
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I’m used to insurance companies declining to pay a consultation charge for an Orthopaedic Surgeon within 10 days of surgery.
The reality is that this does not impact only on Orthopods.
I’ve seen it happen with GI Surgeons. And I’ve seen it with ENT clients.
It’s the very reason before I invoice consultations within 10 days of treatment, I ask if the consultation was “routine”. Or if there were additional medical reasons.
But it is only the consultant surgeon who knows why the consultation took place.
If routine, a post-surgical follow-up within 10 days of the surgery, might not get paid.
If on the other hand there were medical reasons, then it is possible.
But how?
It is best to call the insurance company and advise you will be submitting the invoice.
Then provide evidence WHY the consultation was necessary.
Nine out of ten times the consultant will then get paid.
After all the insurance company is NOT the enemy.
But what does throw me completely is when it is an initial consultation that has been declined because:
“Under the patient’s policy benefit is only payable when treatment is related to an eligible in-patient or day-patient stay within six months. Outstanding treatment costs are, therefore, due from your patient.”
How can an initial consultation be refused under such conditions?
It can’t.
What I’m actually being told is that the consultation is not covered under the terms of the policy.
That is different.
I did suggest to the insurance company concerned it amended the wording. It should read: “initial consultations are not covered under your patient’s scheme”
It’s annoying when this happens. You have to speak to the insurance company concerned. The question becomes: why the consultation was declined?
Where I have the problem is asking an unnecessary question. If the insurance company had made it clear WHY the consultation was declined there is no reason to call.
In the time I’ve taken to resolve the query I could have called the patient and obtained payment for the declined consultation for one thing.
pete@medicalhealthcaremanagement.co.uk
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Keep it quiet but I’m a virtual cheater!
First of all, I’m a virtual business.
I’m not physically based in my client’s offices. In some cases I’m hundreds of miles away so I can’t walk down the corridor and tap on a door to speak with a client.
Instead, we communicate by email. We also use a really old fashioned device called a telephone and actually speak to each other. Most of the time that is good enough because normally, as a consultant surgeon, my client is either with a patient or in theatre. So I can’t exactly knock on the door anyway.
Simple. I offer to go meet my clients and have a face to face meeting with them.
Its important for both the consultant and I this happens.
Why?
Because over a coffee or lunch you can talk through any strategic decisions that have or are coming up.
More important than that though, you actually get to know how the client feels.
For example: am I delivering what they expect of me?
How do they feel about the service for which they are paying?
Are there any areas where the client is expecting more or sometimes fewer results?
It gives me a chance to ask the questions and listen to what is being said. And it gives me the chance to respond.
It’s worth it just to listen. And listen intently.
Not with a view to interrupting but with a view to fully understanding what the client is thinking and saying. And why.
It would be very easy for me to only send reports by email to a client and ask for comments.
I do that every week anyway and sometimes the client responds with queries.
Most of the time, he or she doesn’t.
The quarterly meetings (sometimes only twice a year with some clients) makes it much easier to produce excellent results for my client.
For example, I have one client who does not want an excess payment chased from an elderly patient under any circumstances.
Excess payments for all other clients are to be processed every week as standard.
He mentioned this to me at the first meeting we held after I started working for him – 3 months after I started working for him!
Another client isn’t bothered about the age of the patient and wants excess amounts chased just as soon as possible.
A third client likes to hear which patients have an excess, how much and then decide if they can be chased.
I don’t mind which.
I should though because the more the client gets paid, the more I can charge the client.
But its the client’s business and not mine.
Yet all three examples were only identified because, even though I’m a virtual business, I went to meet the client. I listened to precisely what the client wanted and then did it. Even then there are items which require clarification and sometimes email is not the best medium to use.
Modern technology is great.
It really is. I can both send and receive so much data it is untrue.
I can check a fee online in a matter of seconds (I guess it does help that I’ve got access to all the insurance company fee structures though)
Weekly reports are sent to clients without breaking into a sweat even.
Yet all these to me are support roles for nothing ever will or should even match the usefulness of actually meeting a client.
You cannot get the same level of understanding from email. You may get close after speaking on the telephone but in my view you can’t as a virtual business beat actually talking face to face with a client.
Told you I was a virtual cheater.
pete@medicalhealthcaremanagement.co.uk
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A Consultant Surgeon performs an AB1234 worth £525.
At the same time, he performs a DC2468 worth £576.
The patient is insured so an invoice has to be submitted for payment.
Therefore you have to calculate the fee payable by the insurance company.
Easy.
Total is £1,101.
However…
You can’t charge a total of £1,101 i.e. both.
You can only charge 100% of the first code’s fee (£525) and 50% of second code’s fee (£576) i.e. £525 plus £288.
Total is £813.00
The problem though is that fee calculation is also wrong.
Why?
You should charge as follows – 100% of the higher fee and 50% of the lower fee. In the above example, it’s been calculated the wrong way round.
The correct calculation is:
£576.00 for the DC2468
£262.50 or 50% of the AB1234 fee
£576 plus £262.50 =
£838.50.
The potential gain for the consultant is therefore £25.50.
Or look at it another way, if you charge it the wrong way round, the consultant will undercharge and loose £25.50
It becomes a bigger issue as most surgeons perform the same procedures many times a month.
The same error repeated 10 times costs £255 each month.
How easy is it to make such an error?
Very, very easy.
If the consultant surgeon supplies a theatre list most likely he’ll have the codes written down.
But it’s a danger to assume they are written down in the order they should be invoiced.
You must check them and make sure you are billing codes in the right order if you are to ensure the consultant gets paid the right fee for his work.
pete@medicalhealthcaremanagement.co.uk
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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
A value!
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.
pete@medicalhealthcaremanagement.co.uk
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If you find yourself stuck for a specific CCSD code, there is only one place to start in reality – www.ccsd.org.uk
The CLINICAL CODING & SCHEDULE DEVELOPMENT GROUP [CCSD] first appeared in 1997 following the appointment of a healthcare management consultancy group. The healthcare management group was commissioned to both streamline and improve medical codes within the private sector. Over 4 years later and following assistance from over 100 private medical consultants in almost 24 different surgical areas, CCSD codes were established.
CCSD codes are contained within 20 separate anatomical sections and comprehensively describe a typical surgical procedure as well as allocating a specific code against it. At this point, there are in excess of 2,000 different codes.
It is important to remember however that the fee for a specific code is not set by CCSD; the individual insurance company sets it. The CCSD website will enable you to locate a specific code but it won’t tell you the fee for it. For that, you need to contact the specific insurance company with whom your patient holds a policy.
So, how precisely do you find a code?
Go to: www.ccsd.org.uk and then click “CCSD schedules” Navigation is very simple. Enter the treatment description and up will come the code (s). For example:
Enter the word CONSULTATION in the CCSD schedules and you’ll be offered three.
20300 initial consultation
20310 follow up consultation
20330-inpatient consultation
Enter the word FRACTURE and you’ll be offered around 30 different codes each relating to a specific anatomical section. Simply locate the section you practice within and the codes will be illustrated. The complicated part though is knowing the fee for each code from the individual insurance companies.
But be honest, how many of you knew what the initials CCSD stood for before reading this article??
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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:
pete@medicalhealthcaremanagement.co.uk
If you enjoyed this CLICK HERE and read “I WANT TO CHARGE MORE”
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MHM recently completed a project for a private hospital. The project was to investigate why medical insurance companies were not paying.
One insurance company was proving to be particularly troublesome. An analysis of a month’s invoices soon identified why. This particular insurance company required all invoices to be submitted electronically. No problem with that.
Except the invoices were woefully inaccurate. For example, the patient’s date of birth or policy number or pre-authorisation was incorrect. Each and every time this caused the invoice to fail. Thus the invoice was not actually processed for payment. Instead, it was put in a “holding” pile.
To resolve the problem, it was imperative to make sure ALL the details were correct. That way invoices could be correctly processed and not placed in a “holding” pile. It was vital all the details were 100% correct. That was, or so it appeared to be, the root cause of the issue. But what was the cause?
Medical secretaries were of the opinion the hospital receptionist was responsible for getting it right. The hospital receptionist said the medical secretaries were responsible and then they both claimed the person who raised the invoice was responsible rather than either of them.
The reality was that nobody was making sure the data was right.
The spat had caused, over the previous six months, the hospital to be short of many tens of thousands of pounds. Indeed the holding pile was not only greater than the value of average daily outpatient appointments, but it was also STILL growing.
Skip forward a few months. The receptionist obtains the details and checks them. The medical secretary ensures all the details are recorded on patient records accurately and checks them again. The person responsible for medical invoicing highlights on a daily basis ANY invoices which can’t be processed. The holding pile is now less than 0.5% of a MONTH’S worth of invoices.
Is this overkill?
Cash input into the hospital from this ONE insurance company has increased by around 160%. It’s not overkill at all.
And the hospital has realised a little pre-emptive medicine has stopped rubbish in = rubbish out issue.
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I took a phone call from a friend recently who works for one of the major insurance providers. He asked why I was still against the principal of open referral. The benefits for both patients and consultants were obvious in his view.
Without being obtuse, I disagree. Firstly because the question of benefits is being looked at from the wrong angle. Secondly, because it depends on who is “selling” such benefits?
His reply was the standard – the benefits are applicable to patients and are twofold. Firstly, he /she has a choice of private consultant. Secondly, it’s cheaper and this is reflected in the policy premium.
Maybe. But in my experience, I’ve seen and heard slightly different. I’ve spoken to patients who made an appointment with THEIR consultant of choice only to be told by the insurance company they should see another consultant instead i.e. one NOT of their choice. And I’ve not heard of anyone having his or her policy premium reduced because they saw a different consultant.
I’m uncomfortable with a patient calling an insurance company and being recommended to change consultant based on the insurance company’s experience. I’m even more uncomfortable if cost enters into the equation.
E-mail me if you have a different view.
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