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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Earlier this week, a prospective client [an ENT consultant] called MHM and advised he had been forced to stop producing paper invoices. In future he was required to submit all claims to insurance companies electronically. Thus he wished to know two things – why should he and what was in it for him?
Why should he?
Effectively he should because some insurance companies have stopped accepting paper invoices. They have dictated submission of claims is required electronically. The requirement is part and parcel of their recognition protocols. It is only a matter of time before ALL insurance companies stop accepting paper invoices.
What’s in it for me?
A very simple, the ENT consultant surgeon will NOT get paid unless he submits his claims electronically. Paper invoices will be returned unprocessed and unpaid.
But, as MHM advised the prospective client, none of this is as onerous as it appears. The key to invoicing electronically is actually identical to paper invoicing. In both cases the details MUST be accurate. Take for example a current MHM client – a gynae, who previously submitted invoices in paper form but frequently omitted the patient’s policy number and/or the patient’s date of birth. The failure rate of paper invoices was over 26%. Since MHM has invoiced electronically for him the failure rate is less than 1%
The insurance company was previously forced therefore to check all the details at their end. Thus the invoice was delayed and possibly returned to the gynae with a request for more information. In other words it was delayed, as the discipline to successfully complete medical invoicing was not present.
Now consider processing the same gynae claim electronically. ALL electronic submission requires as mandatory that details are complete. If they are not the claim will NOT be accepted. This does not mean it will be paid. It does mean if the details are correct the claim has been accepted for consideration.
So, from the ENT consultant’s point of view and indeed that of the gynae what appeared to be onerous was actually in his own best interests.
Why should I? – You’ll get paid quicker
What’s in it for me? – You’ll get paid quicker
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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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MHM sort of cheats when we say we are an outsourced medical biller.
We don’t share premises with our consultant surgeons nor are we next door to the hospital. Neither do we speak to them every single morning when they walk through the door. We are – literally – miles away from our clients. And so we cheat.
It matters little that we are, in one case 160 miles away from the client or in the case of another 16 miles. We could, in fact, be 16 feet away. The result would be the same. We speak to our clients every day in the first few months. Then it tails off to say twice a week. Then it becomes once a week. One client speaks to us approximately every two weeks.
Why do we let this communication tail off? Actually, it doesn’t. It just changes.
At first, there are hundreds of things to do. There is a lot to understand, and, usually many issues to resolve. As time goes by though and as the process kick in the number of issues reduces and the need for very frequent contact reduces in turn. We also know that consultant surgeons always seem to be chasing the clock. But if communication comes to a full stop then that’s when the problems start.
Once a month a FULL analysis of where the medical invoicing and outstanding accounts stand is produced and sent to the clients. Some read it. Some email and phone with questions. After a passage of time and because the cash is flowing in, most ignore it. Yet still, a monthly report is sent out. Without fail.
But..then we cheat even more.
We go and see the client every two to three months and sit down with them (sometimes for no more than an hour) to chat through problems, meet their med-secs, and, get to understand how they feel about things. Are there any areas they think or feel should be better? Are there areas where they thought it was worse than it actually turned out to be?
In short, a very open yet extremely robust management reporting process underpinned by the opportunity to physically meet and ensure that issues don’t become major problems for both of us leads to a healthy and frankly cash positive result all round.
So..what has YOUR experience of outsourcing been? What are YOU looking for?
I already know what you are looking for – a solution to your medical billing problems or, in simple terms, to get paid quicker with less hassle.
Let me know what else you are looking for, please?
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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
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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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 protocol 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 query 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. 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 to 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 few 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: firstname.lastname@example.org
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At a medical 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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One of the major areas MHM is approached about is excess and shortfalls.
As at May 2015, 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 only 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 made.
So what can the private consultant surgeon do about it?
The number one rule in tacking the thorny issue of excess deductions is to identify when they happen. This is actually very easy. The remittance from the insurance company WILL confirm when an excess or shortfall deduction 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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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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A question we were asked very recently. One in fact we are asked frequently!
There are a few very simple reasons why on-line invoices are not being accepted – the details being submitted are incomplete and/or the details being submitted are wrong.
MHM is a big fan of electronic invoicing and uses it wherever and whenever possible. But it does depend totally on one item – absolute correct data. For example: if you try and invoice electronically you will almost certainly be asked to state the patient’s date of birth and the patient’s postcode. If either is incorrect or is missing then you will NOT be able to invoice. This in fact goes back to a consistent requirement of making sure you or your secretary obtains the correct details. Let’s put this in perspective. In 2014, MHM was asked to review the billing of a large private medical practice. The issue was the practice was owed significant amounts of money and could not get paid by one specific insurance company who insisted invoices should be sent electronically. MHM reviewed 100 invoices all of which had failed to be accepted electronically. In well over 60% of the cases either the patient’s policy number was missing or date of birth was missing or the patient’s post code was missing / wrong. The practice manager responsible for this had, to resolve the problem, decreed the invoices should be sent in paper form instead. A clear case of mistaking movement for action! The insurance company concerned, remember, had stated invoices should be sent electronically and ONLY electronically.
There is no such thing as a quick fix to this. Indeed a quick fix – such as sending invoices in paper form instead – often leads to even more problems as it does not resolve the cause of the issue.
MHM suggested going forward ALL patient details were captured correctly and the data verified with NO exceptions. We then took the “old” invoices and corrected / completed the data.
Within 4 months the average monthly cash flow into the practice had increased from around £120k a month to £260k a month.
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This specific issue comes up frequently when MHM is asked to review the outstanding accounts of a private consultant surgeon.
There are two reasons normally why the patient believes the hospital have taken payment for the consultant:
To overcome this, MHM recommends the client’s invoice bears the message “payment of this invoice is not covered by any debit / credit card details taken by the hospital” To further help prevent the issue arising, MHM recommends that when the patient makes the booking for the initial consultation, he/she is told an invoice will be sent to them after the consultation.
Over the last year, twice MHM has amended the surgeon’s invoice to include the above sentence. In both cases, the number of outstanding self-funder invoices reduced.
To resolve this issue MHM contacts the patient and request they check what was and what was not covered in the package. Payment of the surgeon’s initial consultation fee soon follows as the patient agrees the initial consultation fee is not covered. BUT again when the consultant’s secretary confirms all items with the patient, the patient should have been advised the initial consultation was not covered.
Actually, on this specific point why has the patient been advised the invoice for the initial consultation is still outstanding if appropriate.
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This issue came up at the MDU meeting on “Setting Up a Private Practice” recently. A delegate enquired as to the difference between the two and what the difference can lead to in terms of shortfalls:
The delegate was an Orthopaedic Surgeon who was suffering from an increased number of deductions and wished to understand why.
Benefits – the values insurance companies pay to the Orthopaedic Surgeon on behalf of their insured patient in line with the terms of the patient’s policy.
Fees – the professional fee charged by the surgeon to his patients for his services
There is a big difference between the two.
For example if the orthopod charges the insurance company patient a fee of £250 but the insurance company benefit is paid out £190 there will be a shortfall of £60 due from the patient. Have 10 shortfalls a month and he is immediately out of pocket by £600.
Not understanding the difference between benefits and fees shortfalls therefore soon adds up to a potential significant loss.
But it’s not quite as simple as that.
Some Health Insurance Companies request the consultant to become “fee assured”. In this case the Orthopaedic Surgeon – just like any other healthcare professional – can only charge a fee which the insurance company agrees. Normally the FEE equates to the BENEFITS payable by the insurance company and hence there are no shortfalls. Sounds great! Save of course benefit fee may be less than the Consultant fee!
As an aside consider some consultants still charge LESS than the PMI are prepared to pay and / or continue to loose money due to shortfalls.
The issue gets really complicated because even if the consultant has charged a fee in line with the PMI level, shortfalls still arise. Normally this happens when the total costs exceed the total benefit payable under his or her policy.
For example: take a patient with £5,000 worth of benefit. Consider the patient who has incurred consultation fees, test fees, surgeon fees, anaesthetist fees, and hospital fees and out patient fees. They may total, for example, £5,250. Thus the shortfall is £250, which will be owed to the one of the medical professionals involved in the treatment.
Obviously if the patient’s policy has £10,000 worth of benefit there won’t be a shortfall but the point I’m making is that generally speaking the emergence of shortfalls is driven by the benefit available and not only the value of fees being charged.
So, if the total benefits are £5,000 but the total fees are £5,250 there is a shortfall due of £250 from the patient. The Orthopaedic Surgeon concerned was unaware of such shortfalls and/or did nothing about them, thus they rapidly built up and would easily have totalled many thousands if left unattended.
But now he understood the difference between benefits and fees, how they had lead to shortfalls.
AND he was now in a position to do something about them.
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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. Consequently, 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 each. No problem except Patient ONE’s insurance company fee structure is £1,600 for an E1910.
Patient TWO’s insurance company fee structure 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 issue.
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, by using the fee structure for Patient ONE only, has undercharged by £164
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.
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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