This blog could easily have been called ‘YOU WON’T UPLIFT A FEE BY DOING THAT”
Recently a private consultant – the colleague of a current client in fact – called me with a problem.
Sadly it was a problem very much of their own making!
In an effort to increase fees, the consultant had decided that a surgical episode should be billed as follows: AB1234 £640 and CD2468 £75. So the total fee = £715.00 and on March 1st, 2019 the insurance company was sent an invoice for £715.0.
And promptly proceeded to reject it.
The fee for the AB1234 was and still is correct.
But with this particular insurance company offering 50% of a second code, the CD2468 fee was wrong to start with. It should not have been £75. It should have been £37.50. Great. Save the invoice would still have been rejected.
Why this time?
If the private consultant had checked they would have discovered that this second CD2468 code was deemed by the insurance company to be part and parcel of the AB1234 procedure.
Thus it was never going to get paid anyway and it was deemed unbundling to submit an invoice and charge for both items.
Skip forward to September 2015. The consultant – or more accurately his long-suffering secretary – has called, emailed and written to the insurance company because the consultant is still unpaid the £640 for the AB1234.
Hence the phone call to MHM.
For once even I couldn’t do anything about the multi-code element.
It very clearly states on the insurance company website that a consultant cannot invoice a CD2468 alongside an AB1234.
In fact, it also says so on the CCSD website.
It is deemed unbundling to do so. The bottom line is that from June 2019 to September 2019 the consultant has been £640 out of pocket.
MHM called the insurance company and has confirmed the original invoice has now been canceled and re-submitted an invoice for an AB1234 £640.00. It is being paid too.
Moral of the story?
You will NOT make more money by unbundling.
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At a recent presentation, I was asked about the costs and use of accounting software.
Bearing in mind the presentation was to consultants who had not yet established a private practice, numerous eyebrows were raised when I answered…
This does not mean accounting software is unnecessary, expensive or unsuitable for an established practice.
Some private practices do need a software package and there are some fine software packages out there.
They are cost-efficient too. MHM works, very successfully, with many of them.
But for those seeing say 10 or 12 patients a week use MS Excel or Apple Numbers and an online diary.
MHM has more than a few clients and uses Excel to run a sales/debtors ledger.
The invoice can be sent as a PDF attachment to an insurance company. The sales ledger – once password protected – can be sent either to the client and/or the client’s accountant.
If a private practice is a business – and it is – then you MUST keep an eye on all costs. If you do not, profit will reduce.
It’s always useful to ask yourself the question.
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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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Working for consultant surgeons is fun.
However, since one particular private medical insurance company decided to outsource their help desk or their “advisors” late last year, there has been a marked reduction in their level of customer service from it.
Considering the people calling them are either consultant surgeons or calling on behalf of a consultant surgeon, that is pretty bad.
Indeed the average time on hold for this particular insurance company, for example, is now well over 10 minutes.
That’s pretty awful considering it used to be less than a minute.
What is ironic however is that now I have a choice of music to listen to.
For example: would I like to listen to classical music, pop music, jazz or rock music? I decided on classical as it happens and am currently listening to Bach. I like Bach.
But it has got me thinking…
Isn’t being given the option of what to listen to missing the point entirely?
This is an even worse option than being told my “call is important to us” and then the call is unanswered.
Shouldn’t the aim be to answer the phone call rather than offering a choice of music to listen to?
All private consultant surgeons sooner or later will need to speak to an insurance company.
Whether this is at the point they are attempting to gain recognition or to check a fee is correct is not relevant.
Sooner or later – particularly if you are billing an insurance company – you have no choice but to speak to them.
But is it absolutely necessary to call?
That is my favourite question to ask.
The first port of call so to speak is always to consider if an action is necessary. In other words, what is causing that action to be necessary and can anything be done to prevent the necessity of the action?
In the case of speaking to a medical insurance company, in theory, many of the calls should not be necessary.
If an invoice is raised and submitted correctly for example then payment should – again in theory – just flow through. Reducing the necessity of speaking to an insurance company is always a good aim.
It is the very reason I check remittance advice sent by an insurance company most carefully.
They record many of the details as to why an invoice, for example, hasn’t been paid either in full or partially.
For example: if a partial payment has been made the reason why will be detailed on the remittance advice.
Thus the number of calls required to a private medical insurance company will be reduced.
Nonetheless, the fact remains there will ALWAYS be an occasion to call an insurance company. It may be, for example, that the fee has been reduced and you don’t know why.
The point is there may be genuine reasons why it IS necessary to speak to an insurance company.
Contrast this however with another insurance company I’ve spoken to this morning. I called them and was told I was on hold, was caller number 3 and the estimated hold time was 4 minutes.
Fine; I can live with that.
It is up to me whether I’m prepared to wait in line or call back.
Having formally complained to the medical insurance company in the first example that their customer service is not good four times so far, I did consider WHY they had outsourced?
It would appear the reason is financial. It’s cheaper.
It was once said by an extremely wealthy man that price is what you pay and value is what you get. I agree wholeheartedly.
Cheaper isn’t always the best.
And time is money too.
I’ve actually written this blog whilst being on hold and listening to Bach. So I’ve used the time to do other things too. What would happen, however, if I was a private consultant surgeon with an already overworked medical secretary who had letters to type or worse still was on hold so patients couldn’t ring her?
That would reflect badly on my practice.
I’m all in favour of outsourcing.
I would say that though because my business is intrinsically the provider of an outsourced facility to private consultant surgeons.
Even so, I get seriously frustrated at being told either my call is important – well answer it then – or I’m offered a choice of music to listen to.
I don’t actually want either to hear either.
I want my issue resolved quickly and efficiently.
Cheaper and slower shouldn’t be an option.
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If you get the basics right many problems with getting paid aren’t allowed to happen.
As a result, accidents aren’t allowed to happen.
The basics are as follows:
Patient’s full name
Their full address including their postcode
The Patient’s date of birth
Policy number of insurance company.
A pre-authorisation number issued by the insurance company
Correct CCSD code
But it doesn’t stop there.
Your name and address
Your provider number
A unique invoice number
Date of the treatment/consultation
But if you don’t get all 14 on your invoices you make it harder for the insurance company to pay you.
Where do you get the above data from?
If you are practicing from a private hospital almost certainly the above will be recorded on the hospital’s registration form.
If you are invoicing electronically, its pretty much standard that you MUST have the above data immediately to hand anyway.
The same is also true if you are dealing with a self-funding patient or you endure having to collect a shortfall/excess amount from a patient.
In other words, the chances are you are going to need all 14 pieces of data. Therefore it makes more sense to get them right the first time.
But the proof of the pudding is very much in the eating. Have a guess at what are the TWO major reasons an insurance company does NOT pay your invoice?
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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?
A 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 it’s been passed for the 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.
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 lose 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.
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.
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 assume the argument fees should not be reduced will be successful.
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.
It’s 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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How can I charge more for my work?
This always spins off into a debate concerning how private medical insurance companies are the enemy.
Fees are always being reduced with the private surgeon being paid less and less it is claimed.
That may be true sometimes but is not the right place to start.
The right place to start is to make sure the private consultant surgeon is charging the correct fee.
Such fee may be less than the surgeon wants of course but, many times, be more than he thought he was entitled to.
Take the example of an orthopaedic surgeon who contacted MHM to process her medical invoices recently.
She was of the opinion her consultation fees were too low. That also may be correct. But that was the consultation fee the insurance company was prepared to pay.
In reality, 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 pays a fee of £336 whereas insurance company B pays £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 £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 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 will quite happily pay MORE for your work.
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I’m a really, really impatient person. I like everything done yesterday.
Which is why I go incredibly slowly to start with.
When I begin to raise invoices for a consultant surgeon, for example, I’ll check I have the right provider number. I’ll check all the online systems and EDI protocols are 100% accurate. Is the consultant’s address correct?. I’ll check the insurance company has the right BACS payment details.
What I’m actually doing is reducing down to absolute zero as many reasons as I can possibly think of that will prevent the invoice being raised correctly.
What happens if I don’t take this approach?
Invoices come flying back. They don’t come back straight away of course.
It may take weeks before I’m notified there is a problem. Then I have to work out why it went wrong, get all the details to put the error right, actually put it right and then resubmit the invoice.
Then I have to wait again for the invoice to be reprocessed. Eventually, the invoice gets paid.
One absolutely true example. Recently MHM project managed a group of three surgeons in the Midlands. All three were seriously considering closing the practice as they were not making any money. They were not getting paid as they should.
The senior of the three was responsible for invoicing for all three each week.
Just under 50% of the invoices he produced came back unpaid. The insurance companies concerned requested more details or raised queries against them.
The senior consultant complained he hadn’t got enough time to keep sorting these things out. He had to raise invoices as quickly as possible. He tended to view any medical invoicing problem from the “quickest fix” point of view. To use his words “I only want to be a surgeon and not a whatever-you-call-it”
My kind of guy. Don’t talk about it. Get on with it. Play to your strengths. Save that is precisely what he was not doing.
He jokingly told me his blood pressure was sky high due to the constant stream of invoice problems.
Yet it was this “quickest fix” approach that was the cause of his blood pressure. Many times his quick fix in one area (get them on the phone or treat the patient as a self-funder for example) caused a problem in another area. Then he had to fix that.
This was leading to a six /seven-week delay before invoices were accepted by insurance companies on top of the agreed payment terms.
It took me two months to re-map the process, test, amend it and bed it in. In month three we started to see the results. The invoice failure rate had dropped from roughly half to below 6%. Cash flow had doubled. The time with which the three consultants got paid decreased from around every 75 days to about 50.
All three consultants were happy. Imagine the surprise though when I told them that wasn’t good enough?
I thought we should see at least a 98% acceptance rate and be paid every 30 days. And I wanted to achieve that as of yesterday starting with raising the invoices every single day rather than weekly. The invoice process was robust. There were very few errors. There were no reasons why we shouldn’t be paid.
Told you I was impatient.
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A Scottish colleague called me last week. A case of “can I pick your brains for two minutes?”
I’m always happy to take such calls for many times I have called others with precisely the same request. My colleague was confused as to what could or could not be charged alongside a consultation fee. Specifically, the consultant surgeon she worked for was administering injections at a consultation and she thought she could not charge a consultation fee AND a fee for the injection. She thought this would be a clear case of unbundling.
Except she was wrong.
Her consultant was perfectly entitled to charge a separate fee for the injection.
A quick analysis of the outpatient consultations where my colleague had NOT charged since January 2015 revealed she had UNDERCHARGED by a total of £837 so far this year. She had however and quite rightly charged for every single consultation – failure to do otherwise is the fastest way to lose the private consultant’s money – but had shown on her invoice the fee for the appointment alongside a ZERO fee for the injection. In the case of one single insurance company she had failed to charge in respect of 9 separate patients £450 worth of injections (9 @ £50 each)
The bottom line is that if she undercharged injections by £837 in the first 6 months of 2015, should she continue throughout 2015 she would lose her consultant £1,674 for the entire year.
How did I know the answer to this one? MHM has clients in the same specialism as my colleague’s consultant. Also, MHM checks fees every 90 days with all insurance companies for the rules of what can and cannot be charged, what is bundled and what is deemed unbundled change. Plus, most importantly, applicable fees alter!
How many of you check what the correct fee is? Not just when you set the practice up but on a regular basis?
But I can’t help but wonder how many consultants undercharge – are you one of them but don’t realise it?
For more details email: email@example.com
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At a conference recently a friend of mine was discussing the future of the private practice industry and what lay ahead.
My colleague shared the view that the “younger” newly appointed consultant is more adaptable to the direction of change in the private practice.
Thus they were a major driver in how the industry moves forward.
I say they are entrepreneurs.
Let me explain why.
Certainly newly appointed consultants cannot look forward to a hefty NHS pension at the end of their career.
The younger consultants are also facing a squeeze in fees from private medical insurance companies. Not to mention they journeyed through a number of years to reach the position they are in now.
Yet they find themselves in an increasingly competitive market.
The market is more competitive than those who came before them. The younger consultants are, so the evidence suggests, much more open to a business orientated approach than before. They have to.
In other words, the newly qualified consultant still has a mortgage to pay, mouths to feed, etc so is much more receptive to being an entrepreneur.
Say what you may but the fact remains the private medical healthcare environment is changing. Just as the NHS healthcare environment is changing.
At the forefront of such changes will be the newly qualified consultant surgeon. To adapt or take advantage of such opportunities as may arise, the new qualified are using technology as never before. For example, they are much more amenable to the use of internet-based technology for marketing and PR. They have to be entrepreneurial.
To prosper, let alone survive, they must invest in technology. What is interesting is that they are more willing to do so than ever before.
To succeed with a private practice requires a significant amount of seriously hard work. This is not to suggest the application of medical skills is not important. It is.
But what is equally important are entrepreneurial skills. Marketing, financial expertise, and business managerial skills for example. These should not be assumed to be easy. They now have to be acquired.
Consider that a consultant – newly qualified or otherwise – works within the NHS.
The NHS provides a support infrastructure including premises, secretarial support and, crucially, a constant supply of new patients.
In the private sector, none of these items will be supplied. The consultant has to go out and actively find them for himself.
And that is why the consultant surgeon should be viewed as an entrepreneur.
Does anyone have a different view? I’d be delighted to hear from you.
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Following a recent blog regarding websites, I was asked my view of social media eg Twitter or Facebook. Whilst in my view a private surgeon should have a website, social media may not be the right place to be unless EXTREME care is exercised.
Any social media utilised by a private surgeon which also allows a patient to post comments thereon might well be a recipe for disaster.
Consider the untold damage if the patient posted on-line the care by the Surgeon was first class but the standard in the hospital was awful.
Guilt by association. Even worse if the patient posts online that the care administered by the surgeon was poor!
One consultant recently expressed the view that the only difference in 2019 to when he started many, many years ago is that now patients no longer merely gripe to friends and family. They can also go online.
An excellent point indeed.
His view is to always perform the best job he can. Just as he should do. That will stop patient complaints. But sooner or later somebody will complain.
MHM is often asked the question which clients have the healthiest private practice. For sure, those that have a website tend to fall into this category. Interestingly though, not one of those clients engages in social media.
So the conclusion may well be not only could social media be a dangerous place to be but, thus far, it has not proved to generate additional patients either.
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One of the major areas MHM is approached about is excess and shortfalls.
In October 2019, empirical evidence indicated 26% of all claims to private medical insurance companies are subject to an excess/shortfall. This is not to imply the insurance companies are to blame.
The reality is that patients have reduced the costs of their premiums over the last few years by agreeing to a higher excess.
But the knock-on effect of this has been an increase in excess deductions.
So what can the private consultant surgeon do about it?
The number one rule in tacking the issue of excess deductions is to identify when they happen. This is actually easy. The remittance from the insurance company WILL confirm when an excess has been made. It most likely will also state their insured (the patient) has been notified.
But under no circumstances should the problem be left at that.
The practice must, at the very least, action all shortfalls straightaway. Under no circumstances should this be allowed to exceed 7 days. Excess or shortfall deductions made again MHM clients are actioned within 48 hours. Such action may be an invoice for the amount of the excess/shortfall immediately sent to the patient. The invoice must state how much is due, why and how it should be paid.
This must be followed by a very robust process that makes sure such invoices are followed up.
If you want a complimentary PFD of the invoice MHM uses for excess or shortfalls, email me at the address below:
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The first thing to realise about increasing a fee is that you CANNOT increase a fee for all your surgical episodes. Nor can you increase a fee every time you perform a surgical episode.
Having said that it is possible on occasion to request an uplift in fee under certain circumstances. The question of time taken, however, to perform the actual episode is not in itself the first reason to request an increase in fee.
All insurance companies WILL consider a request to increase fee but the time duration of the episode is not the place to start.
It is the “what, when & how to ask” that is the most important item to consider.
What, for example, might be defined as a 50% increase in the stated fee.
Do NOT merely ask for a 100% increase in fee because the probability is that you will not get it!
When? The “when” may be defined as asking for an increase to be considered before an invoice is submitted.
How? This may be defined as having the correct information in order for the increase to be considered.
When MHM is asked to request a 50% increase in fee MHM asks its client to supply the following information:
a. The precise details of why medically the consultant feels his fee should be increased. In other words, a written explanation from the consultant as to why the episode was more complicated than anticipated. The consultant is also asked to provide a copy of his/her theatre notes.
b. Details from the anesthetist who provided his/her services during the episode
c. Copies of correspondence from the Hospital detailing the original schedule i.e. time allocated etc.
MHM will then call the insurance company concerned and advise them a fee increase is being requested.
It will tell the insurance company a fee increase from say £500 to £750 is being requested. It will advise the insurance company all the information is available and ask where the supporting documentation is to be supplied.
Only then will an invoice be raised and submitted. It is then a question of checking the invoice every single week to ascertain the status of the invoice.
By following the above process MHM has on numerous occasions obtained an increase in the fee for its clients.
Without following the process, you probably won’t get an increase in your fee.
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Some consultant surgeons aren’t fully familiar with the fees paid by different medical insurance companies for the same surgical episode.
They actually undercharge without even realising it.
Surgeon A is an ENT consultant surgeon. He performs an E1910 on two different patients. He bills both the patient’s insurance company £1,600. No problem except Patient ONE’s insurance company fee structure is £1,600 for an E1910.
Patient TWO’s insurance company fee structure, however, is £1,945 for the same E1910 episode.
Surgeon A has therefore by invoicing Patient TWO’s insurance company £1,600 i.e. the fee he gets from Patient ONE’s insurance company undercharged by £345
Surgeon B is a gynaecologist but has the same problem.
He performs a Q0800 on two different patients who are insured by separate insurance companies. He invoices both insurance companies at £636 each. Save Patient ONE’s insurance company’s fee structure is £636 whereas Patient TWO’s insurance company’s fee structure is £800.
Surgeon B has undercharged by £164
Both carry on billing not realising that the fee depends on whom the patient is insured with.
To illustrate 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 medical insurance companies we checked, £636, £676, £775 and £800.
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. Don’t assume they are the same because they may not be. A published medical fee for the consultant surgeon can and does alter not only between private medical insurance companies but can also alter over time. In every single case, it’s always worth checking the fee structure paid and not assuming it is the same across all private medical insurance companies.
Normally, of course, the medical secretary is assumed to know who pays what. But to expect an already overworked medical secretary to check each time before she bills is, in plain English, not really an option.
Invoice for two different codes in the same surgical episode incorrectly and it’s 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.
It’s even more fun when careful attention is not being paid and 100% of the LOWER value fee is claimed and 50% of the HIGHER value fee, as well as both fees, being lower due to the insurance company the patient is with.
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Take, for example, a patient who requires an injection which may be performed by a private orthopedic surgeon at an outpatient consultation.
Thus you raise an invoice for, as an example, £185 [£90 for the consultation and £95 for the injection]. Please be aware for the purposes of this article the values are fictitious!
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 and argue that is the right thing to do.
It is often suggested that the alternative 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 a case, the consultant CAN charge for both.
Not sure that’s in the patient’s best interests. But if the aim is to max revenue it is certainly in the best interests of the consultant. I’m certainly not saying its right or wrong. I am saying it’s an option.
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 a 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.
Gets a whole lot worse when the injection is pre-authorised as the fee for a consultation is higher than that for the injection, the orthopaedic surgeon charges for the consultation only yet the insurance company is expecting an invoice for the injection.
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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MHM recently completed a project for a hospital. The project was to investigate why the hospital was not getting paid.
One insurance company was proving to be particularly troublesome. An analysis of a month’s invoices soon identified why. This particular insurance company requires all invoices to be submitted electronically.
Except the invoices were woefully incomplete. 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.
To resolve the problem, it was imperative to make sure ALL the details are correct. That way invoices will be correctly processed and not placed in a “holding” pile. That was, or so it appeared to be, the cause of the issue.
Or was it?
Medical secretaries though the hospital receptionist was responsible for getting it right. The hospital receptionist thought the medical secretaries were responsible. Then they both said 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 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. Worse 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%.
Is this overkill?
Cash input into the hospital from this ONE insurance company has increased by around 160%. It’s not overkilling at all.
And the hospital has realised a little pre-emptive medicine has stopped rubbish in = rubbish out issue.
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Consider when the patient has contacted his/her insurance company and been issued with a pre-authorisation number.
This does not mean, the insurance company will accept your charge.
This happened to an MHM client – a gynaecologist – a few days ago. We spoke to the insurance company concerned. They confirmed whilst they did indeed issue a pre-auth, this did not mean they would accept the charge. In fact, pre-authorisation had been refused.
Yet again the message came through loud and clear:
No argument from me on that one. It has always been so.
My issue though is why did the insurance company issue a “DECLINED” pre-authorisation?
If they were not prepared to issue a pre-authorisation then they should not have issued one at all.
This point was duly made to the insurance company. Their reply was poetic.
They had always done it that way.
I have the utmost respect for private medical insurance companies. Most are extremely efficient and willing to help. Whilst I’ve had numerous disagreements with all of them regarding fees etc, never have they implied or stood behind the “we’ve always done it that way” position.
But on this occasion, it feels very much like a case of stop wasting your breath!
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Recently my stepdaughter received confirmation from her GP additional tests were required for an issue that had arisen.
Both she and her Mum were somewhat disturbed that the waiting time for the test would be over 2 months. As my stepdaughter had private medical cover through her employer, she duly contacted her insurance company and was authorised to see a private consultant. Off she went. No issues and a precautionary follow up arranged for a couple of months later. The benefits of having private medical cover were apparent – much shorter waiting time.
Mindful of the world I’m in, I asked if she was sure she was covered for everything. Yes, she replied; she hadn’t checked because her employer-provided the policy, therefore, she was fully covered. So I waited for the “oops – no I’m not” moment.
Sure enough, shortly after, a letter arrived stating that whilst the test was covered by her insurance the consultation(s) themselves were not. How could this be? She had contacted her insurance company and been authorised. Her insurance company made the classic reference to the small print when the point was pursued further. By no means am I suggesting all PMI companies fail to point such things out but empirical evidence indicates sometimes they don’t?
So why had the fact consultations were NOT covered been left unexplained to her?
The other classic reference of it being her responsibility to check the exact offering of the policy was made. That just doesn’t cut it for me. The PMI should have been completely transparent and explained what was or was not covered. This is something my guys (more specifically their med-secs) are asked to bring to the patient’s attention when the initial consultation is arranged. Again and again I both see and hear patients stating they were unaware that certain items are not covered by insurance.
They have private medical insurance and that’s the end of it as far as they are concerned.
It’s why MHM clients are advised to enquire if their patient has confirmed precisely what is or is not covered by their private medical insurance.
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My website designer friend related a really interesting tale to me this week.
He designs websites for all sorts of businesses including consultant surgeons but was confused. He’d checked the traffic to all his client’s websites and the numbers were good. Curiously though, the traffic to some medical websites indicated a significant difference from those of other medical websites. He couldn’t understand why.
That night he mentioned this to his wife and asked her the question of why. Took her all of 10 seconds to notice that traffic to the website for gynecologists was higher than that of the others. And therein lay a clue to the answer apparently. In her view, women were much more likely to check out their consultant’s websites than we males. Really??
Later that week, I asked my better half the same question. And got exactly the same reply (and a bewildered look for not spotting the obvious too)
So an exercise first undertaken some years back was repeated. The patients of the various consultant surgeons were asked if they had looked at the consultant’s website. Sure enough, women – regardless of the specialism – were shown to be significantly higher than men when it came to reviewing the consultant online.
Then my friend and I both made a fatal mistake.
We both asked our respective partners if that was due to women being more curious than males? BAD move!
We were both, “politely advised” it was more likely to be because women generally speaking take much more of an interest in their health and weight than we males, etc.
Sexist but true??
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