Top up (or GAP) invoices = asking the patient to agree to pay the difference between a consultant’s fee and the fee an insurance company is prepared to pay.
The discussion concerning them seems to take place more in whispers than anything else.
And sometimes they are even deemed to be almost a taboo subject because they don’t exist.
But they do.
So, and for the record:
I have no problem issuing them on behalf of my clients.
Why and when?
Consider the case of a real consultant surgeon whose patient is quite happy to pay, for example, £852 for a surgical episode.
But the patient is insured with XYZ Insurance.
XYZ will only pay a “customary and reasonable fee” of £639.
The fee was £852 but due to “market conditions” XYZ has reduced it by 25%.
Thus the consultant may now as part of his recognition protocol only charge £639.
Most consultants actually perform the same procedure throughout the month.
Empirical evidence using MHM clients confirms they all perform, in their own specialism obviously, the same code(s) on average 5 times a month.
If that code happens to be the one reduced by £213 each time, the reduction in revenue is over £1,000 each month.
In the original scenario though, the patient has chosen to see that particular consultant.
His/her decision has zero to do with fees.
That is the consultant the patient has chosen.
If the patient is advised the fee for their procedure is £852 but their insurance company will only pay £639 towards it and then if they – the patient – is asked beforehand to pay the difference and agrees, where is the problem?
Ah no, say the insurance company, you can’t do that for that is above our stated fee schedule so you are risking your recognition with us if you do.
This article is not about if they are right to potentially withdraw recognition if fees are not adhered to.
Neither is it about whether XYZ Insurance is right to reduce the fee.
The first thing consultants will all do is be deeply unhappy about the reduction.
The second thing they will do is attempt to mitigate the loss somehow or another.
And the second point is the more relevant one.
Many times I hear from insurance companies the market is contracting and cost has to be taken out to make the private medical insurance offering more attractive.
But why is the cost reduction, or so it appears, being continually directed at the consultants?
Yes, I am aware that certain fees have gone up but overall fees have come down.
I’m equally opposed to those consultants who insist on ignoring insurance companies’ fee structures for every single procedure and/or episode.
I’m also very focused on taking costs out of any business so I can see where the insurance companies are coming from.
But not at the expense of continually reducing a consultant’s fee and thereby reducing his profit continually AND the patient’s right to a choice.
Top Up or Gap invoices are a reaction to consultants continually seeing their fees being eroded.
I haven’t said I completely agree with them for they should be unnecessary.
What I am saying is that I understand why I’m being asked to produce them and when.
Consider an actual quote to me recently from a very well established consultant surgeon.
An orthopod who has been in private practice for over 10 years:
That, perhaps, sums up precisely why some MHM clients are asking me to produce Top Up or GAP invoices.
pete@medicalhealthcaremanagement.co.uk
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I didn’t say I was against remote consultations!
Following yesterday’s post, I received phone calls and emails claiming clearly I was against remote consultations.
But I never said that!
What I said was that I don’t think remote consultations are a vehicle by which a private practice will grow.
Specifically, there is insufficient data upon which to believe they WILL grow a private practice. It’s far too early to make that claim.
Whilst they are easier for the private consultant to perform, and more crucially, enable to patient to be “seen”, that does not in itself mean the patients will want them.
I suspect many patients much prefer a face to face consultation over a remote consultation anyway.
Could it be patients are happy with remote consultations because they have been told to stay home?
That said I freely admit I could well be wrong but maintain it is far too early to reach a conclusion either way.
There’s another aspect to this.
What fee will the consultant receive for a remote consultation?
At this point in time, all insurance companies are paying precisely the same fee for a remote consultation as a face to face consultation.
Quite right too.
But that does not mean, in the post-Covid-19 world they will continue to do so.
Prior to the lockdown, fees for remote consultations were substantially lower than those for face to face consultations.
At some point, it is inevitable that insurance companies will resume their previous fee structures.
All of which means as a growth opportunity, remote consultations could well be less attractive than first thought.
But remote consultations should remain an option in the post-Covid-19 world.
As such they should be offered to patients.
But they won’t be the panacea to private practice as suggested.
pete@medicalhealthcaremanagement.co.uk
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I was at a medical conference recently and one of the speakers – a well-established consultant surgeon and an incredibly safe pair of hands – stated during his presentation that a private surgeon could not charge for inpatient care.
He may well be a safe pair of hands but on that point he was wrong.
After the conference, I had a word and said he was incorrect. It IS possible to charge for inpatient care.
I couldn’t help but suggest to him that the mere fact there was a separate code for inpatient care indicated it could be charged.
Obviously, it may well depend on the insurance company concerned. In principle, however, it is possible to charge. I knew I was right because I’d actually charged for inpatient care for an MHM client a few weeks earlier. And the invoice had been paid.
But he wouldn’t budge.
He was right.
I was wrong.
Skip forward a few weeks and I received an email from my consultant surgeon friend confirming that I had been right all along and he had been wrong.
Why is it sad that I had been right?
Because my consultant surgeon friend has been in private practice for well over a decade and he’d NEVER charged for inpatient care.
More significantly though, my friend had not checked each month what could and could not be charged for.
That also begged the question if the fees he was charging had been checked with the same frequency too. He hadn’t so as a favour I checked for him.
The good news is that only 3 of his fees had altered.
The bad news is that one of them had gone up £107 five months earlier yet he was charging the old and lower fee.
Thus it is important not only does a Private Consultant Surgeon need to establish what he can or can’t charge for, it is just as important to check HOW MUCH you can charge for!
pete@medicalhalthcaremanagement.co.uk
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In terms of medical billing, this perhaps is one of the statements I say to private consultant surgeons more frequently than others.
The following example illustrates that despite the rejection of the fee how the fee was established confirms there is little the consultant can do about it.
The consultant surgeon concerned had applied to be recognised by a private medical insurance. MHM had spoken to the consultant and pointed out fees should be confirmed when recognition was being arranged. The consultant was well qualified, had held a substantial NHS post for a number of years and his/her specialism was in high demand. The private medical insurance company was keen to offer recognition. Thus recognition was granted.
Yet despite the warning by MHM fees had not been checked.
MHM was subsequently asked to handle the medical billing side. In order to do so, we need to know how much consultation fees were. The medical professional, however, did not know what the consultation fees were. Thus alarm bells immediately started ringing.
Consultation fees would have agreed to and would have been detailed in the pack supplied to them by the insurance company concerned as we had advised. So we called the insurance company and quoted the newly acquired provider number.
As usual, the insurance company was keen to point put the consultant had agreed to adhere to the published fees.
It is always amusing when “fair and reasonable” is quoted to me because it depends on what the consultant thinks is “fair and reasonable”. More specifically what happens if the thinking differs between the two parties concerned. And that is precisely what happened in this example.
The insurance company deemed that £175 was a fair and reasonable fee for a consultation.
The medical professional deemed that £250 was a fair and reasonable fee.
And thus the consultant instructed MHM to charge consultation at £250.
MHM pointed out that it would indeed charge £250 as instructed. All that would happen, however, is the insurance company would reduce the value of the invoice down to the £175 originally agreed.
And that is precisely what did happen.
Despite the medical professional objecting strongly to a consultation fee of £175 and insisting a “fair and reasonable” fee was £250, the invoices were reduced in value.
It mattered little to the insurance company that the MHM client had colleagues who were both charging and getting paid £175.
Even before I asked the question I knew this was to be true. It mattered even less to the insurance company that a second colleague was paid even more than £175. This was so because the second colleague was in a completely different specialism!
Sadly the MHM client had based their practice business plan on a consultation fee of £250. They had done so because they had asked colleagues how much they were paid. Then they had assumed such fees would equally apply to them.
MHM, per normal, had no issue calling the insurance company concerned and arguing the case on behalf of the medical professional.
That said it was an argument that it was never going to be won. The simple reason remained that at the point of recognition the MHM client had accepted the fees.
Sure enough, the insurance company stood firmly behind its agreement with the consultant.
ASSUMPTION LEADS TO PROBLEMS.
The moral of this sorry tale is best summed up by the above heading. I’m not suggesting you shouldn’t challenge fees for consultations or indeed a surgical episode but don’t put yourself on the back foot by accepting fees and then challenging them afterward. As painful as it is for the MHM client, it really is as simple as that.
Check your fees before you agree to them!
pete@medicalhealthcaremanagement.co.uk
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Following last week’s article regarding how you should always keep good relations with a private medical insurance company, it is worth pointing out that this does NOT mean you have to agree with them.
The following incident, for example, happened this week.
An MHM client recently performed a Q1800. The episode was pre-authorised (meaning the patient’s policy was intact). The fee was £280.
Then the problems started. The insurance company paid the consultant £103 so I called and asked why.
Post the issue of the pre-authorisation, indeed after the surgical episode itself took place the published fee had been reduced to £103.
£177 or 63%!!
A number of issues immediately came onto the table.
Firstly, the fee of £280 applied at the point the surgical episode took place. It was wrong for the insurance company to reduce it afterward.
Secondly, £103 is a ridiculously low fee for a Q1800.
It is precisely the same fee as payable to the anesthetist working with the consultant during the surgical episode. At the risk of upsetting my anesthetist friends out there, that can’t be right.
Thirdly, the fee is lower than the surgeon’s initial consultation fee when he saw the patient in the first place.
A Q1800 (so I’m told) is not a minor procedure which can be carried out during a consultation. It is a “full” surgical episode requiring a theatre, anesthetist and theatre staff.
Thus I had a lengthy conversation with the insurance company concerned and advised them, should they insist the fee remained £103, we would be sending a shortfall invoice to the patient for the additional £177.
Normally, that is NOT a step I would take.
All MHM clients are advised to set their fees precisely in line with those of the relevant insurance company.
On this occasion though, I genuinely thought, and still do, the actions of the insurance company were unacceptable.
It is wrong for an insurance company to reduce a fee after a surgical episode.
A heated discussion took place regarding my view and that of the insurance company concerned.
They remained firmly of the opinion it would be wrong for MHM to send an invoice for the £177 shortfall to the patient. Absolutely not in my view for the “contract for treatment” is between the consultant and the patient.
A fact, insurance companies point out to me with frequent monotony. It is the insurance company’s actions that had led to this action.
Nor is it relevant that other consultants in the same specialism have accepted the fee reduction.
I’m not acting for them. I’m only interested in MHM consultant surgeons.
A fee of £280 was originally agreed. That is the fee which should be paid.
Finally, the insurance company agreed it was unacceptable to reduce a fee after the date of an episode. Therefore the additional £177 will be paid.
But in future, the fee for a Q1800 would be £103. That is an issue for another time but I can foresee further conflict if other fees are reduced by 63%.
Do not however always accept a private medical insurance company are always correct in their actions and decisions.
Whilst the majority of decisions are acceptable, sometimes they might not be.
pete@medicalhealthcaremanagement.co.uk
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Most consultants when they first start a private practice, consider how best they can set their fees. In reality, it is not the consultant who sets his or her own fees. It is the patient’s insurance company.
Consideration of fee setting should be viewed from two distinct areas:
1: Consultation fees 2: Surgical Fees
Consultation fees first.
Consultation fees (for both initial and follow up) will be agreed at the point of recognition by the respective insurance companies of the medical professional e.g. consultant surgeon, anesthetist, etc.
Clearly, if you have 20 years experience and are one of the few consultants within your geographic area, then you may be able to command a higher fee.
In reality, most likely you not be in such a position. You will be offered consultation fees at a level set by the insurance company you are dealing with. In return, the insurance company will refer patients to you.
In the case of self-funders, however, there is nothing to stop you charging any consultation fee you like. Save of course if there are other consultants in your area then their fees will influence that which you charge.
Surgical fees, if anything, are the easier one to deal with.
The insurance company with whom your patient is insured will always set surgical fees. You may feel the fee is too low and therefore charge more. Almost certainly your invoice WILL be rejected. Keep sending invoices in for fees greater than that allowed by a particular insurance company and you run the risk of being de-recognised.
Whether it is right or wrong for insurance companies to hold such power over the setting of surgical fees is for another article. I have very firm views on it but at this point, the stark reality is that the insurance companies do hold such power.
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Many times, consultant surgeons have approached MHM because they, as consultant surgeons, don’t like asking patients for the money.
And from a certain point of view, this is exactly how it should be. New MHM clients don’t, however, remain MHM clients if they are in the profession just for the money. That said, what happens if you don’t ask for the money?
Firstly, most private patients are insured. Therefore MHM is asking for payment from an insurance company and not a patient. Secondly, if there is an excess or shortfall etc, most patients will pay such excess when they are asked.
If you don’t or are afraid to ask for the money there is a high possibility you won’t be paid.
Private practice is a business. It may be a business where patient welfare comes first, second and third as it should and in certain cases a patient should NOT be asked to pay but fundamentally a private practice is a business.
Ask for the money.
pete@medicalhealthcaremanagement.co.uk
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This issue came up recently with a consultant surgeon.
How are fees accounted for against a benefits package?
Consider the total benefits payable under a patient’s policy. For example, the benefits payable is £100.
It could be more. The fees mentioned below could be higher too.
Against such a benefits package, fees are deducted thus:
Initial: £20.
The £20 is paid out. The total benefits figure reduces to £80.
Subsequently, the patient requires surgery. £50.
This is also paid.
The accumulator reduces to £30.
Finally the hospital tenders their account: £20. The gasman submits his: £10. The benefits accumulator, therefore, reduces to ZERO.
The benefits package is equal to the fees.
However….
If the initial is £21, the surgery £51, the hospital £21, and the gasman £16 then the total fees = £109. Against a total benefits package of £100.
Thus, if fees exceed the total benefits a shortfall will be created.
pete@medicalhealthcaremanagement.co.uk
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A normal item when I get asked to review a consultant’s invoicing process is the potential for weakness in the area of records on his/her part.
Sometimes, I’m presented with a carrier bag full of invoices, remittances, and receipts. My favourite though remains the cardboard box stuffed full of pieces of paper and being advised that’s the filing system. Close examination of the pieces of paper in the cardboard box suggested they were
My favourite though remains the cardboard box stuffed full of pieces of paper and being told that’s the filing system. Close examination of the pieces of paper in the cardboard box suggested they were
Close examination of the pieces of paper in the cardboard box suggested they were invoices. Most did not have an invoice number on them. Indeed the majority did not actually have the word INVOICE printed on them either.
That can be a problem when I come to reconcile payments against such payments. IF they’ve been paid at all. That is important because it is difficult to contact an insurance company and discuss invoices for one individual patient if the invoice does not show an invoice number. In
In fact, the only way you can tell them apart is if the values are different and they are on different dates.
It’s always best to have a unique reference number on an invoice i.e. an invoice number and a date.
Then the hard part starts as you begin to look at what is or is not on the invoice and get a feel for what was likely to be paid anyway and what was likely to be rejected due to total lack of detail.
Normally this is followed by a request to see clinic lists and the process of obtaining the right data off the clinic list for submission to the insurance company.
There is also an additional cost to not keeping accurate records. When it comes to tax time, its going to take a lot longer – and thereby cost much more – for your accountant to do the necessary computations. At worse you could end up paying too much tax.
All because records aren’t kept correctly.
pete@medicalhealthcaremanagement.co.uk
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One of the most common mistakes made by a private consultant surgeon when invoicing is undercharging for their work. This is alarming when considered against the question most asked by a private consultant surgeon.
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 orthopedic 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 the achilles tendon. Insurance company A pay a fee of £336 whereas insurance company B pay £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 the £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 a 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 also that some, not all but some, private medical insurance companies will actually and quite happily pay MORE for your work than you may be aware of.
pete@medicalhealthcaremanagement.co.uk
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One of the most often asked questions is “how as a private consultant surgeon can I improve or increase my cash flow”.
The answer, as regards medical invoicing, is very simple to answer:
But what does that mean in reality? It means taking all the items that should be done and turn them into a MUST be done. For example, I took a phone call from a consultant’s secretary this morning who wanted a favour. She was struggling to get an invoice posted electronically. She was trying to invoice BUPA. Simple enough you may think but despite having a policy number, she could not process the invoice.
So how did it take me approximately 3 seconds to work out precisely WHY she couldn’t process the invoice?
She told me the policy number began BI-6000 etc.
That told me the policy number was not a BUPA policy number; it was a BUPA INTERNATIONAL policy number. She was trying to invoice the wrong insurance company. A quick fix to process the invoice, again online, to BUPA International and it sailed through. Sorted.
If standards had been raised to ensure that every single patient registration form had been completed correctly, this problem would not have occurred. The invoice would have been processed the same day and payment made when required. Instead, a shortcut had been attempted and the patient’s insurance company detailed incorrectly. If standards had been raised to ensure this was checked and spotted the invoice would have been immediately processed. There are no shortcuts if you want to get paid. As it happens in this case the issue was already a week old before I took the phone call.
Thus an increase in cash flow – the outcome desired by the private consultant – was not being reached.
However, if you stop to think there are two questions:
When the patient was registered, why wasn’t the check performed to ensure the right insurance company was recorded because it should have. What should have happened was the standards had been set too low. If it becomes a case of the patient MUST be asked i.e standards are raised then this specific problem is never allowed to arise.
And that’s what I mean by raising your standards.
So why is this even more crucial as we work our way toward 2018?
Because more and more private medical insurance companies are insisting invoices be submitted electronically. The issue is not one of is that the right thing for them to do or not. The real issue is that it is happening and standards must be raised to ensure you CAN invoice electronically. In other words, if you don’t have all the right details it is much, much harder to process an invoice electronically. You will instead have to re-contact the patient and get the right details.
Therefore it makes more sense to say you MUST get the details upfront and you must RAISE YOUR STANDARDS to the point of saying – the correct details MUST be obtained and checked.
I’ve even witnessed where an invoice can’t be processed because the postcode has been recorded as W01 (numeric) when it should say W01 (alpha) Incidentally.
Many times I’ve said insurance companies are not the enemy. Even if I frequently disagree – I do on a daily basis sometimes – with some of their fees plus other items they do which are seriously irritating, all insurance companies will pay a private consultant IF (and only if) ALL the details are correct. In other words, invoices must be raised to the correct standard.
If you want to increase or improve your cash flow, the very first thing to do is to raise your standards in the area of invoicing.
pete@medicalhealthcaremanagement.co.uk
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In terms of medical billing, this perhaps is one of the statements I hear from private consultant surgeons more frequently than others.
The following example illustrates that despite the rejection of the fee how the fee was established confirms there is little the consultant can do about it.
The consultant surgeon concerned had applied to be recognised by a private medical insurance. MHM had spoken to the consultant and pointed out fees should be confirmed when recognition was being arranged. The consultant was well qualified, had held a substantial NHS post for a number of years and his/her specialism was in high demand. The private medical insurance company was keen to offer recognition. Thus recognition was granted.
Yet despite the warning by MHM fees had not been checked.
MHM was subsequently asked to handle the medical billing side. In order to do so, we need to know how much consultation fees were. The medical professional, however, did not know what the consultation fees were. Thus alarm bells immediately started ringing.
Consultation fees would have agreed to and would have been detailed in the pack supplied to them by the insurance company concerned as we had advised. So we called the insurance company and quoted the newly acquired provider number.
As usual, the insurance company was keen to point put the consultant had agreed to adhere to the published fees.
It is always amusing when “fair and reasonable” is quoted to me because it depends on what the consultant thinks is “fair and reasonable”. More specifically what happens if the thinking differs between the two parties concerned. And that is precisely what happened in this example.
The insurance company deemed that £175 was a fair and reasonable fee for a consultation. The consultant had signed agreeing to £175
The medical professional deemed that £250 was a fair and reasonable fee.
And thus the consultant instructed MHM to charge a consultation at £250.
MHM pointed out that it would indeed charge £175 as instructed. All that would happen, however, is the insurance company would reduce the value of the invoice down to the £175 originally agreed.
And that is precisely what did happen.
Despite the medical professional objecting strongly to a consultation fee of £175 and insisting a “fair and reasonable” fee was £250, the invoices were reduced in value.
It mattered little to the insurance company that the MHM client had colleagues who were both charging and getting paid £250.
Even before I asked the question I knew this was to be true. It mattered even less to the insurance company that a second colleague was paid even more than £250. This was so because the second colleague was in a completely different specialism!
Sadly the MHM client had based their practice business plan on a consultation fee of £250. They had done so because they had asked colleagues how much they were paid. Then they had assumed such fees would equally apply to them.
MHM, per normal, had no issue calling the insurance company concerned and arguing the case on behalf of the medical professional.
That said it was an argument that it was never going to be won. The simple reason remained that at the point of recognition the MHM client had accepted the fees.
Sure enough, the insurance company stood firmly behind its agreement with the consultant.
ASSUMPTION LEADS TO PROBLEMS.
The moral of this sorry tale is best summed up by the above heading. I’m not suggesting you shouldn’t challenge fees for consultations or indeed a surgical episode but don’t put yourself on the back foot by accepting fees and then challenging them afterward. As painful as it is for the MHM client, it really is as simple as that.
Check your fees before you agree to them!
pete@medicalhealthcaremanagement.co.uk
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Surgeon A is an ENT consultant surgeon. He performs a E1910 on two different patients. The surgeon bills both patient’s insurance company £1,600 each.
Patient ONE’s insurance company fee structure is £1,600. Patient TWO’s insurance company fee structure is £1,945 for the same episode.
By invoicing Patient TWO’s insurance company £1,600 i.e. the fee he gets from Patient ONE’s insurance company, the surgeon has undercharged.
The surgeon will be paid £345 less than he should.
A similar issue was faced by Surgeon B. He is a gynaecologist. He 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.
Patient ONE’s insurance company’s fee structure is £636 however whereas Patient TWO’s insurance company’s fee structure is £800.
Surgeon B, by using the fee structure for Patient ONE only has undercharged and been paid £164 less than he should.
Both carry on billing not realising that the fee depends on whom the patient is insured with and different private medical insurance companies publish different fees for the same surgical procedure.
We checked four different medical insurance companies this afternoon in order to confirm the fees for an E1910. The 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 of the four medical insurance companies we checked, £636, £676, £775 and £800 respectively.
Don’t set fees at the level published by a single insurance company.
Check which fee is paid by which insurance company for the same procedure. Do not assume they are the same because they may not be.
A surgical fee can and does alter between private medical insurance companies. It can also alter over time.
In every single case, it’s always worth checking the fee structure paid by the patient’s insurance company. Do not assume it is the same across all private medical insurance companies.
Invoice for two different codes in the same surgical episode incorrectly and its 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!
pete@medicalhealthcaremanagement.co.uk
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It is not a “nice to have” anymore. It is a necessity.
Consider the following real MHM clients. Surgeon A is a very forward thinking. Surgeon B can’t even update his Iphone [keeps forgetting his password]. Both performed a similar number of surgical episodes and outpatient consultations in March 2017. Every single one was invoiced.
Today is April 28th.
Client A – shortfalls / excess against his March work totalled about £1,600. Today he has £42 worth of excess and shortfalls still outstanding.
Client B – shortfalls / excess against his March work totalled about £1, 510. Today he has £967 worth of excess and shortfalls outstanding.
Both had their shortfalls / excess invoiced to their respective patients in precisely the same way. Client A saw a 98% success rate in collection of shortfalls / excess. Client B only saw a 35% success rate.
WHY?
Surgeon A – I take on-line payments.
Surgeon B – I do NOT take on-line payments.
You should see his website! You can see his availability by clicking on his on-line diary. You can’t book a consultation but you can see where and when his clinics are for the next two months.
He has a website too (took me 8 months to convince him to get one). He does NOT like on-line payments. He doesn’t trust them. I’m not allowed to use the MHM on-line payment facility.
For Surgeon B I’m going have to chase down his patients more than Surgeon A. Doesn’t bother me. I’ll collect Surgeon B’s excess and shortfalls eventually. I get paid the same amount for both clients. It costs both of them the same. I just have to put more effort in for SurgeonB to get my fee – big deal (not). So I’ll have to make numerous reminder phone calls for Surgeon B. For client A I’ll have to make a phone call or two.
But if I were Surgeon B I’d be irritated if I were still owed £967 for my March work.
I spoke with him yesterday and came out with my “dinosaur thinking” comment (again). I described what was happening with Surgeon A. Per normal he laughed. He pointed out that whilst he was not planning on becoming extinct just yet, he still didn’t like the idea of on-line payments.
If you want to use MHM to reduce the number of excess and shortfalls you have outstanding, email me at the address below:
pete@medicalhealthcaremanagement.co.uk
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This issue has come up a few times over the years.
Consider if, during the initial consultation, you advise your patient surgery is required.
The patient is therefore given a CCSD code equating to the surgical episode to quote to his or her insurance company. He goes away, quotes the CCSD code to his insurance company and is given a pre-authorisation code for, as an example, AB1234 by his insurance company.
The patient then contacts your secretary and passes over the pre-auth number.
Everybody is happy.
But what happens if, during surgery, you realize a change of surgical procedure is necessary?
Does it make a difference?
Not to the patient.
It also doesn’t make a difference to you either for you have performed the surgical procedure you deemed to be the absolutely correct procedure at the time.
The point at which it does make a difference, however, is the fee the amended surgical procedure attracts. For example:
The original code of AB1234 may, for example, generate a fee of £452.
But if during surgery, a different procedure was necessary a different code will be applicable.
For example XX4268 instead of the original procedure code of AB1234. XX4268 generates a fee of £619.00 whereas AB1234 generates £452.
So the question: which code do you charge for?
The XX2468 obviously.
There is a step to be taken before the invoice is raised.
The best practice is to call the insurance company and explain the situation.
All insurance companies are very used to such calls from MHM. Some request a letter from the consultant surgeon explaining why the change was necessary.
Some do not.
And thus MHM invoices the correct fee and you get paid the right fee.
What happens if you do NOT make the call to the insurance company and just invoice for a different CCSD code to that authorized?
Having never ever done that I wasn’t sure. So I called two of the major private medical insurance companies.
Both said the same.
At best the invoice will be seriously delayed pending their request for an explanation. In the worse case, the invoice will be declined.
pete@medicalhealthcaremanagement.co.uk
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I’ve been asked to re-published the following which first appeared last year.
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, may 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 to 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.
pete@medicalhealthcaremanagement.co.uk
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I was at a medical conference recently and one of the speakers – a well established consultant surgeon and an incredibly safe pair of hands – stated during his presentation that a private surgeon could not charge for inpatient care.
He may well be a safe pair of hands but on that point he was wrong.
After the conference I had a word and said he was incorrect. It IS possible to charge for inpatient care.
The code for inpatient care is 20320.
I couldn’t help but suggest to him that the mere fact there was a separate code for inpatient care indicated it could be charged. Obviously it may well depend on the insurance company concerned but in principle, it was possible to charge. I knew I was right because I’d actually charged for inpatient care for an MHM client a few weeks earlier. And the invoice had been paid.
But he wouldn’t budge.
He was right.
I was wrong.
Skip foreword a few weeks and I received an email from my consultant surgeon friend confirming that I had been right all along and he had been wrong.
A private consultant surgeon MAY charge for inpatient care.
Why is it sad that I had been right?
Because my consultant surgeon friend has been in private practice for well over a decade and he’d NEVER charged for inpatient care.
More significantly though, my friend had not checked each month what could and could not be charged for. That also begged the question if the fees he was charging had been checked with the same frequency too. He hadn’t so as a favour I checked for him. The good news is that only 3 of his fees had altered. The bad news is that one of them had gone up £107 five months earlier yet he was charging the old and lower fee.
Thus it is important not only does a Private Consultant Surgeon need to establish what he can or can’t charge for, its just as important to check HOW MUCH you can charge for!
pete@medicalhalthcaremanagement.co.uk
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Many MHM clients have asked what I think the future holds for their fees?
A number of private insurance companies have reduced fees for consultations and for surgical episodes over the last few months and years.
One insurance company, for example, dictated newly recognised consultants must accept lower fees than their colleagues who had been recognised some years earlier. It was inevitable that at some point the previously recognised consultants would be asked to accept the lower fees too. And that point was reached recently looking at some of the emails forwarded to me.
Certainly, the more established consultants can and have tried to refuse acceptance of the new fees.
Some have accepted the new lower fee but decided to pass the difference between the old and new fee on to their patient as a shortfall. Their solution has been problematic. The refusal has often been met with the threat of de-recognition by the insurance company concerned.
I know of one consultant surgeon who instructed “gap” invoices should be sent to the patient. An invoice for the difference between the old, higher fee and the new, lower fee. He wasn’t an MHM client otherwise I would have told him what was likely to happen.
The act of issuing an invoice and passing on a shortfall by a fee assured or fee guaranteed consultant will and has resulted in the same de-recognition scenario.
Whilst MHM never has and never will be in favour of constantly reducing consultant’s fees, the often quoted insurance company argument of fees being dictated by “market forces” is both mischievous and, in some cases, wrong.
But we are where we are.
What is disturbing though is when MHM talks to new clients the number of cases where the maximum correct fee has not been charged. More specifically, where a lower fee has been charged than the insurance company was happy to pay.
Insurance companies do have a habit of reducing fees.
But they increase fees too.
Certain surgical fees have gone up recently. Fees should be checked very regularly to make sure you ARE charging the right fee.
So, what next for a private consultant’s fees?
The assumption has to be that pressure on fees to reduce will continue.
Nonetheless, the assumption the private consultant is charging the right fee in the first place should and must be challenged for you may, in fact, be undercharging.
pete@medicalhealthcaremanagement.co.uk
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We all hear that many times during the day.
It’s a pain but sometimes it literally is a case of not being able to provide an answer there and then. In itself that is not a problem.
Where it IS a problem is when you don’t get the return phone call.
Personally never mind it being unprofessional to not return a call, I think it is simply rude. Often it can result in a loss of business too. For example:
Recently I was approached by a potential MHM supplier.
We’d done business before. The supplier was keen to provide his services again so we agreed on a meeting. I have an existing supplier but I have to look at all avenues.
Sadly, and these things happen, the potential supplier had to cancel and said he’d get back to me with an alternative date the following day.
No problem.
But the next day came and went without a call.
So did the day after.
Therefore I called his mobile and left a message for him to call me back. He didn’t. The following day I called again. Whilst he answered he wasn’t at that precise point able to offer an alternative date. But he would call me back “this afternoon” You guessed it, he didn’t. The next day I left another message to call me. He didn’t.
Skip forward to the next week. He finally called me to re-arrange the meeting.
It did occur to me whilst all this was going on that I might not be a significant account to him. I only paid him £200 a month previously. But that is £2,400 a year.
It’s also £2,400 worth of business he won’t be getting off me. I declined the meeting.
As I pointed out to him this was not because I was being difficult or vengeful or even showing my irritation.
It was solely because, to me, his lack of manners and his haphazard approach had not inspired any confidence on the future delivery of his service.
A service incidentally that not only I use but all of my clients could potentially use in the future.
All because, and to quote him directly, “I haven’t had the time all week to stop and return your call”
I resisted the temptation to point out that was his problem and not mine.
I also resisted the temptation to point out his comment made me feel my £2,400 a year wasn’t worth it to him.
I’d have actually preferred a call saying a £2,400 per annum contract wasn’t big enough for him. I would have respected that even.
I mentioned this tale to a family member last evening who happens to be a Regional Sales Manager for a large local company.
He was horrified. Indeed he advised if one of his sales team had done something like that, they would have been invited to consider their future elsewhere (Ok – he put it somewhat stronger really!) I have to agree.
Not returning a phone call is very unprofessional and can very easily lead to a loss of business.
pete@medicalhealthcaremanagement.co.uk
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This issue has come up a few times over the years. Indeed, I’ve already been asked the question twice during 2016 and it’s only January 11th too.
Consider if, during the initial consultation, you advise your patient surgery is required. The patient is therefore given a CCSD code equating to the surgical episode to quote to his or her insurance company. The patient goes away, quotes the CCSD code to his insurance company and is given a pre-authorisation code for, as an example, AB1234 by his insurance company. The patient then contacts your secretary and passes over the pre-auth number. Everybody is happy.
But what happens if, during surgery, you realise a change of surgical procedure is necessary? Does it make a difference? Not to the patient. It also doesn’t make a difference to you either for you have performed the surgical procedure you deemed to be the absolutely correct procedure at the time.
The point at which it does make a difference, however, is the fee the amended surgical procedure attracts. For example:
The original code of AB1234 may, for example, generate a fee of £452. But if during surgery, a different procedure was necessary a different code will be applicable. For example: XX4268 instead of the original procedure code of AB1234. XX4268 generates a fee of £619.00 whereas AB1234 generates £452.
So the question: which code do you charge for? The XX2468 obviously. But…
There is a step to be taken before the invoice is raised. Best practice is to call the insurance company and explain the situation. All insurance companies are very used to such calls from MHM. Some request a letter from the consultant surgeon explaining why the change was necessary. Some do not.
And thus MHM invoices the correct fee and you get paid the right fee.
What happens if you do NOT make the call to the insurance company and just invoice for a different CCSD code to that authorised? Having never ever done that I wasn’t sure. So I called two of the major private medical insurance companies. Both said the same. At best the invoice will be seriously delayed pending their request for an explanation. In the worse case, the invoice will be declined.
pete@medicalhealthcaremanagement.co.uk
by Read more →