Surgeon A is an ENT consultant surgeon. He performs a E1910 on two different patients. He bills both the 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.
Consequently, he will be paid £345 less than he should.
A similar issue was faced by Surgeon B. He is a gynecologist and has the same issue. He performs a Q0800 on two different patients who are insured by separate insurance companies. Both insurance companies are charged £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 fees 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!