I’ve been asked to revisit why coding is such a big part of medical invoicing.
It is integral because without the correct code the chances of getting paid decrease. It is unlikely if you wish to invoice electronically you will be able to invoice without a code anyway.
Insurance companies use medical coding to identify and detail a procedure. For example, an Orthopaedic surgeon will understand precisely what a Multiple arthroscopic operation on the knee is.
But that’s a lot to put on an invoice. Plus there may be variations on the episode.
Instead, use the code W8500. That will specifically identify the surgery you have done.
If you are planning to invoice electronically you won’t be able to input the whole description anyway.
So where do you find the code?
CCSD 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, Simply Health and Vitality Health.
Its main purpose is to maintain a common standard of procedure codes. Such codes reflect current medical practice within the private healthcare sector. They are published as the CCSD Schedule of codes.
The various insurance companies will, therefore, recognise the majority of codes.
However, a word of caution.
Whilst the example above of W8500 will be recognised, a CCSD code does not come with a suggested fee rate.
The fee rate for each code is up to the individual insurance company concerned. To find the correct fee for the code, you will need to check with that insurance company.
For example, the W8500 mentioned earlier carries a fee of £615 for one insurance company. For a different insurance company, the fee may be £550. If you charge £550 instead of £615 by mistake, you will NOT have your fee increased.
If however, you charge £615 when it should be £550, your fee will be reduced.
Whilst not so important for consultations, a CCSD code is imperative IF a surgical episode is required. The patient must quote the code to his or her insurance company when pre-authorisation is being requested.
When an invoice is sent to the insurance company, the code should appear on the invoice, This 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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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. Rather 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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A question we were asked very recently. One, in fact, we are asked frequently. But what is the problem?
There are a few very simple reasons why online 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. But electronic invoicing does depend totally on one item. Having the correct data. For example: if you try and invoice electronically you will need the patient’s date of birth and the patient’s postcode. If either is incorrect then you will NOT be able to invoice.
This goes back to a consistent requirement of making sure you the details are correct.
The first and ONLY place to start is the patient’s registration form.
If this form is not completed or there are errors, the problem will manifest itself in the fact an invoice can’t be raised electronically.
In 2017, MHM was asked to review the billing of a large medical practice. The issue was the practice was owed significant amounts of money and could not get paid by one specific insurance company. MHM reviewed 100 invoices all of which had failed to be accepted.
In over 60% of the cases either the patient’s, policy number was missing or date of birth was missing or the patient’s postcode was 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 mistakingmovement 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. A quick fix – such as sending invoices in paper form – often leads to more problems as it does not resolve the cause of the issue. Many insurance companies will no longer not accept paper invoices anyway so you might as well get it right up front.
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.
pete@medicalhealthcaremanagement.co.uk
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It actually happened too.
Consider a CCSD code for a follow up consultation = 20310. Now consider the CCSD code for an ECG = 20110.
A consultant surgeon couldn’t understand why he was not getting paid the right values for his follow up consultations i.e. £150. Instead, he was getting either £72 from one insurance company, £96 from a second or zero a third. The reason was clear when MHM investigated.
It was because some of the invoices for his follow-ups consultations had been coded as 20110 [ECG reporting] and not 20310 [follow up consultation]
Insurance companies were seeing 20110; some were querying the code when the patient hadn’t had an ECG but others were happily paying the fee for the 20110. The third insurance company did not cover 20110 ECG as part of their patient offering and thus declined to pay anything.
When numbers were audited the average discrepancy was £65. When all numbers were in, the number of errors equaled 11. And thus the client was out of pocket by approximately £725.
The consultant concerned was not happy, especially when his work did not require an ECG anyway. Thus one day’s analysis and the consultant now receives the right fee – because the right code and fee are being used.
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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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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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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.
www.medicalhealthcaremanagement.co.uk
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Take for example, a patient who requires an injection which may be performed by a private orthopaedic 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!
BUT….
Upon receipt of the invoice by the patient’s insurance company, the value is rejected; as 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. That said, its already been suggested that the alternative and better way 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 case the consultant CAN charge for both.
Not sure that’s in the patient’s best interests though but if the aim is to max revenue its 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.
Confused yet?
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.
Feel free to drop me (Pete) an email if you’d like to learn how to avoid the perils of unbundling.
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Some insurance companies decline to accept invoices that are sent more than six months after the consultation or surgical episode. Fair enough, they should have been invoiced.
BUT…
A statement was received today from a certain insurance company containing an entry reclaiming £620 paid to an MHM client in December 2013. Whilst that was before MHM started managing the client’s medical invoicing, a phone call to the insurance company was made anyway. All part of the service. 20 minutes later the insurance company concerned confirmed the payment of £620 had NOT in fact been made to the client in December 2013!
In other words, they were totally wrong to deduct money from the MHM client. The insurance company is paying back to the MHM client the £620 at the end of the month. We’ve just saved the client £620 – result.
Hang on a second. This particular insurance company does indeed decline invoices over six months old. Yet it makes deductions from an MHM client going back not months but years. And the deduction was wrong anyway.
Moral of the story?
ALWAYS check the payment remittances from an insurance company. 99% are correct but that last 1% can be worth hundred of £’s!
How many of you have had this happen to you? More importantly how many of you realise it has happened?
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Many months back a medical secretary friend of mine suggested the MHM approach of writing the address on an envelope to a self-funder or for an excess/shortfall looked unprofessional. The address should be typed in her view, presentation being everything.
My reply was that an envelope with a typed address could easily be mistaken for some kind of circular or indeed as junk mail. She was having none of that argument and insisted her view was correct.
Skip forward several months and we met up again. She asked how MHM were finding self-funders and excess charges and specifically were we getting them paid? In answering we stated we, like her, had seen an increase. Nonetheless we were having them paid. She apparently was seeing the same increase in numbers but significantly was seriously struggling to get them paid. Many times she called a patient to be told the invoice hadn’t arrived.
When I mentioned writing the address again, she stopped and thought about it again.
She called me this afternoon. Since she stopped typing the address and writing it instead, she’s seen an increase in the number of paid self-funders. She is also seeing an increase in the number of paid excess / shortfalls too.
Learning to write did come in useful after all!
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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 enquiry regarding a patient.
In the ideal world, you will have:
The Policy Number Patients name Patient’s FULL address The POST CODE (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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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. Rather 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
by Read more →