Every so often I take a phone call from a self funding patient. The patient requires a receipt for their payment. The patient can then re-claim the amount paid from their health cash plan provider.
For example: a patient visits a private surgeon and pays for their treatment. MHM issue a receipt on behalf of the surgeon. The patient can then claim the fee back from their Health Cash plan provider.
The Cash Plan Provider insists on a receipt as proof of payment before reimbursing the patient.
Alternatively the patient is insured but outpatient appointments are not covered under their policy. The patient has to pay before claiming the funds back from another source.
So what are Health Cash Plans?
Health Cash Plans are designed to ease the financial burden of having such regular health checks.
They are NOT the same as a private medical insurance policy.
Well on some occasions it has indeed transpired that the patient’s private medical insurance cover does NOT include outpatient appointments. Other items may be excluded too. Instead the patient has a health cash plan to cover the cost of their treatment.
But unlike full blown insurance cover, the patient is required to pay the charges they have incurred. They then re-claim the payment from the Health Cash Plan provider.
And that’s why they require a receipt.
Thus it is important to understand what a Health Cash Plan is and how it may compliment a private medical insurance policy.
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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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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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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 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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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.
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This issue came up during a recent meeting with a consultant surgeon. More specifically how fees are accounted for against a benefits package and the possible creation of a shortfall.
Consider the total benefits payable under a patient’s insurance policy. For example, the benefits payable may be £100. Obviously, it could be considerably more as will the possible fees mentioned below.
To continue, however, against such a benefits package fees are deducted as follows:
The patient attends for an initial consultation at a cost of £20. Therefore the £20 is paid out and the total benefits figure reduces to £80. Subsequently, the patient requires a surgical episode at a cost of £50. This too is paid out and the benefits accumulator, therefore, reduces to £30. But of course, the hospital tenders their account (say £20) as does the gasman (£15). The benefits accumulator, therefore, further reduces to ZERO. Thus the benefits package is equal to the fees charged.
If the initial consultation fee is £21, the surgical episode fee £51, the hospital account £21 and the gasman’s account £16 then the total fees total is £109 against a total available benefit package of £100.
Thus, if when the fees are calculated against the benefits accumulator they exceed the total available, a shortfall will be created.
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