Most consultants when they first start a private practice, consider how best they can set their fees.
In the case of self-funders, 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.
Effectively it is up to the patient whether they chose to accept that fee or not.
In reality, in the case of an insured patient, it is not the consultant who sets fees.
It is the patient’s insurance company.
Consideration of fees for an insured patient should be viewed from two distinct areas:
1: Consultation fees
2: Surgical Fees
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.
The insurance company with whom your patient is insured will always set surgical fees.
You may feel the fee is too low and therefore try to 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.
It’s not a good idea to be in such a position.
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 most of the cards.
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Couple of examples recently where consultants have tried to base their fees on the best rate available.
Take the consultant who realises that Medical insurance company Num 1 pay £300 for a procedure. Medical Insurance Company Num 2 however pays £400.
He therefore decrees he will charge Company 1 the higher Company 2 rate each time he performs that procedure.
Great idea. Right up to the point Insurance Company 1 – who the patient is actually insured with – receives the invoice for the higher amount.
As a result, Insurance Company 1 decline to pay that fee and most likely will shortfall it. But, replies the Consultant, no problem because the patient is ultimately liable for any shortfall. Thus he invoices the difference to the patient.
I know of one consultant who has on his website “we use Medical Insurance Company XXX rates to calculate our fees. If there is a shortfall you will have to pay”
The patient may be liable for a shortfall BUT not when the consultant is fee assured he isn’t.
If the consultant is fee assured he has undertaken to charge in line with the specific insurance companies fee schedule. Most likely a letter addressed to the Consultant will arrive pointing out that such “inappropriate billing” is not acceptable.
Inappropriate medical billing is similar to unbundling. Continue doing it over a number of months and for sure eyebrows will be raised. Even if there is no “fee assured” status PMI Company 1 will be well aware of regular and consistent charges that are in excess of their published fee schedule.
Carry on doing it and the number of referrals to the consultant by the insurance company will reduce. Ultimate the consultant’s recognition with the insurance company is at risk.
Not withstanding the above, of course consultants want the best possible fee for a procedure but attempting to obtain a higher fee by “inappropriate billing” is not the smartest way to go about it.
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Surgeon A is an ENT consultant surgeon. He performs an E1910 on two different patients and 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 gynecologist with the same issue. Surgeon B 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 realizing 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 was £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 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!
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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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Take, for example, a patient who requires an injection which may be performed at a consultation.
Thus you raise an invoice for, as an example, £185 [£90 for the consultation and £95 for the injection]
Upon receipt of the invoice by the patient’s insurance company, the value is rejected. You CAN’T charge both for a consultation and an injection on the same invoice on the same day.
You can charge for one or the other but not both.
So you are paid £90 for the injection only.
What is interesting is that the immediate reaction from some consultants could well be to charge just for the injection.
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 it is certainly in the best interests of the consultant.
Right up to the point the insurance company finds out.
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 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.
Unless you check each consultation and injection episode with the insurance company concerned, you will be!
More likely you will actually undercharge at some point in time.
For example: if the insurance company DOES allow a fee for consultation and injection if you charge only for one sooner or later?
You’ll be out of pocket.
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MHM recently completed a project for a private hospital. The project was to investigate why various private medical insurance companies were not paying.
One insurance company was proving to be particular troublesome. An analysis of a complete month’s invoices soon identified why. This particular insurance company required all invoices to be submitted electronically. No problem with that.
Except the invoices were woefully inaccurate. For example, the patient’s date of birth or policy number or pre-authorisation was incorrect. Each and every time this caused the invoice to fail at the point of logging electronically with the insurance company. Thus the invoice was not actually passed to the insurance company for payment. Instead it was put in a “holding” pile.
To resolve the problem, it was imperative to make sure ALL the details were correct so invoices could be successfully processed and not placed in a “holding” pile. It was vital all the details were 100% correct. That was, or so it appeared to be, the root cause of the issue.
Why was this proving so troublesome?
It transpired medical secretaries were of the opinion the hospital receptionist were responsible for getting it right. The hospital receptionist said the medical secretaries were responsible. Then they both claimed the person who actually raised the invoice was responsible. The reality was that nobody was making sure the data was right and this was before the correct CCSD code was being identified and used.
The spat had caused, over the previous six months, the hospital to be short of money by many tens of thousands of pounds. Indeed the holding pile was not only greater than the value of an average daily outpatient appointments, it was STILL growing.
Skip forward a few months. The receptionist obtains the details and checks them. The medical secretary ensures all the details are recorded on patient records accurately and checks them again. The person responsible for medical invoicing highlights on a daily basis ANY invoices which can’t be processed. The holding pile is now less than 0.5% of a MONTH’S worth of invoices.
Is this overkill?
Cash in-put into the hospital from this ONE insurance company has increased by around 160%. It’s not overkill at all.
And the hospital has realised a little pre-emptive medicine has stopped a rubbish in = rubbish out issue.
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My Top Three Assumptions when there is a knock on the office door are:
What on earth has that got to do with medical invoicing I hear you ask?
Maybe not the first two (definitely not the 1st although the 2nd may have possibilities). The 3rd, however, is very relevant for you really need a positive attitude when you are invoicing for consultant surgeons.
All my guys (and girls) are lovely. They really put some serious hours in. Seldom do they seem to sleep (a throwback to being at med-school and being a “junior” hospital doctor).
Joined up writing is an issue too – I’m being serious!
It is the joined up writing part where you need positive thinking. I once enquired of one of my clients as to why all medical professionals seem to have poor handwriting.
He responded that a Doctor’s ability to write legibly is surgically removed at med-school. Works for me.
I can’t really insist my guys and gals improve their handwriting. But I can and do urge them to send me the clinic lists produced by the hospital instead of writing them out again.
Why re-write something when you can scan the original anyway?
Consequently, that is what they do.
This leads me to have a positive outlook because I know the information I need will arrive in a format I can use to raise invoices correctly.
It also means from the consultant’s point of view once I have the data all the patient details will be checked. All the fees will be calculated. Invoices WILL be raised. I don’t even have to attempt to read the writing.
All in all, a very positive thought.
My clients, therefore, think positively regarding when and if they are going to get paid.
In reality, however, I don’t for a nanosecond believe in the concept of positive thinking.
You may, for example, have numerous positive thoughts that it won’t rain today. Your thoughts will have absolutely no impact at all on the weather and you may (or may not) get wet.
What will have an impact is if you have an umbrella with you? If it doesn’t rain, you won’t need the umbrella. Should it rain, you will.
If you have PREPARED and made sure whether it rains or not, you are in a position to handle it. You have taken ACTION.
It is just the same with medical invoicing.
Don’t just have positive thoughts that all your work is being invoiced.
Have positive thoughts that you will get paid the right amount and on time.
Take positive ACTIONS to make sure your invoices are being raised to ensure you do get paid the right amount and on time.
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A few weeks ago, I was checking what was happening with shortfalls and excess since the start of the year. Using a single private consultant surgeon as an example:
Week ending Friday January 22nd: out of 15 consultations 4 came back with excess / shortfall deductions. The total £575.
So for a total of £2,500 worth of outpatient consultations £575 or 23% came back short.
Looking back to the same week in 2015, the number of shortfalls/excess was considerably less.
The question as to why this is happening is not the immediate concern although I will blog about that next week if anyone wants me to?
The concern is what you should do about it.
If 23% of submitted invoice values continue to come back as shortfall or excess, the downside and potential loss to a consultant surgeon is significant.
What to do about it?
The very first thing to do is to make sure the patient has been invoiced for the amount due immediately. If payment is not received within a week then there is only one subsequent single course of action.
Phone the patient.
Once I have the patient on the phone I take payment via a debit or credit card.
Sure you can write letters and even email but nothing gets a response like a ringing telephone.
Most patients are unaware of the issue (yes I know when they open their policy they are made aware of excess values) but some think this is an issue between them and their insurance company.
In other words, the patient thinks they need to pay the insurance company because the consultant gets paid in full by the insurance company.
There are variations on this but the crucial point for the consultant is not to establish why. The point is to ensure he recovers the shortfall/excess efficiently.
That means speaking to the patient.
But if telephoning the patient is the most efficient way to tackle the issue, it does not automatically follow its the easiest.
It has to be done professionally and with care.
This is not a debtor I’m talking to on the telephone.
It is a PATIENT!
The long-suffering med-sec really won’t have the time to do this as professional and caring as she undoubtedly is.
The majority of medical secretaries won’t want to phone patients for money and will be thinking this is the least enjoyable part of her job.
What if the consultant doesn’t employ someone to tackle this? What if they don’t do anything?
Assume it’s not £575 or 23% a week or £27,600 a year (£575 multiplied by 48 – not 52 weeks as you will have 4 weeks off a year). Assume instead its 10% for 24 weeks (i.e. roughly half) and allows for some patients paying without being contacted.
That’s still £13,800 per annum.
What’s significant is that when speaking to a group of private consultant surgeons I asked what they considered the biggest threat to their practice(s). Most popular is the anticipated further reduction in fees paid by private medical insurance companies. There is little if anything that can be done about that.
The second concern, however, is the number of shortfalls and excess. It’s becoming a big challenge. A challenge that will get bigger in my view.
At this point, empirical evidence suggests its potentially leaving the back door wide open and enduring £13,800 worth of potential losses right off the bottom line.
I’d be really interested to hear from anyone who is seeing an increase in shortfalls etc.
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I called one of my friends early one evening last week. His phone went straight to voice mail. Curiously he didn’t call me back with half an hour or so per normal. He called me this morning instead. He explained why. Every Wednesday, he and his wife have a “date night” They leave their respective phones at home and go out to eat. Or eat then go to the cinema.
No emails, text or phones interrupting them. They spend time talking to each other.
And that got me thinking.
A couple of years ago I started doing something similar. At the end of each day, I’d put my phone on silent and switched my emails off too. Why?
Because each day I need time to review any opportunities/problems I’ve got to deal with the next day. It also means I can think about an issue at length, leave it overnight ready to be re-thought about on the next day. That stops me making knee jerk reactions and allows time to have a fully considered opinion ready. Rarely will you get an immediate reaction from me. My response to an issue has, therefore, been thought through.
Yet many medical practice managers or indeed consultant surgeons running a practice, don’t stop and think through an issue. They are too busy. But alternatively, they are too busy because they don’t stop and think through the issue.
Sadly I see this all too often when I go meet a potential new client. Many of the issues they are facing have their source in a previous decision. The previous decision itself could well be based on a decision before that one even. One of those decisions in the chain was almost certainly not thought through.
For example: recently I blogged about a group of gynecologists in the West Midlands who, in an effort to stop issues with self-funding patients decided ALL self-funding patients must pay in advance.
Immediately the problem with self-funding patients stopped. Because there weren’t any self-funding patients anymore.
This was a solution to the problem. It worked. Sadly, however, it had some unpleasant side effects i.e. no patients.
Clearly, they hadn’t thought through the consequences of their decision. They had reacted. Yet the reaction caused another problem i.e. no more self-funding patients. That was unfortunate as 23% of their practice was derived from self-funding patients.
The above example is indicative of the cause of many of the issues within that particular practice. It was relatively easy to put the self-funding issue right because I’ve faced that specific challenge a few hundred times previously (email me for how). Getting the practice manager and the three consultants to change their mindset though was much more difficult.
They did change though because they had seen a 100% reduction in self-funder outstanding invoices. Sadly this was at the expense of a 100% reduction in self-funder patients.
They changed not just because I knew the answer. They changed because they realised when I faced that issue previously, I’d allowed myself sufficient time to give it serious thought and consideration before reaching a decision. I implemented a course of action that didn’t put patients off by asking payment in advance but did reduce the number of outstanding self-funder invoices. As a bonus, it stopped the problem with self-funding patients who were DNA too!
And that is why it is important to put the time aside and think through an issue before deciding on a specific course of action.
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During a conversation with a friend of mine recently (he is in the medical industry too) I pointed out that our clients had a couple of things in common.
For one thing they are consultant surgeons.
And that means they are all supremely qualified. They are right at the top of the game. They have to be because the patient’s life is sometimes – literally – in their hands.
Then my friend made a really interesting point.
He said as a surgeon (he IS one) both he and other consultants are VERY used to asking for a second opinion from another consultant surgeon.
Yet he could not understand why therefore when it came to running their private medical practice AS A BUSINESS, there seemed to be a reluctance to go out and seek the opinion of an expert in running a private medical practice as a business.
Maybe its because after all the years of training, our clients are so highly trained and skilled they are almost hardwired to perform in a certain way. What is curious is that other professionals i.e. non medical have a similar tendency.
They too are reluctant to ask for expert help.
And there is nothing more dangerous than someone who thinks he knows but in reality doesn’t.
Worse still when he does not realise what he knows is wrong or inappropriate.
THEY DON’T KNOW WHAT THEY DON’T KNOW!
Silly example: my partner and I were having dinner with my friend and his wife recently. My partner (Lord knows why) enquired why ladies were required to remove nail polish or nail gel if they were having a surgical episode? In her opinion it was unnecessary. Because, according to my friend, the theatre staff attach monitors to the patient’s fingers to monitor her and nail gel causes problems with the connection. He knew what he knew but my partner didn’t know what she didn’t know.
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I like the blues. I like Robert Johnson for example.
And I like cash (including Johnny)
What I don’t like is the expression “cash flow”
For the simple reason, cash does not flow.
Cash has to be managed.
Around this time of year, I take calls from consultant surgeons who in view of their impending tax payments require an increase in cash collections.
It’s happened every year since MHM was formed. The normal instruction is to increase the cash flow. Immediately. Simple enough. I can do that.
Existing clients don’t call because invoices have already been generated for them and they’ve already been paid for their work. Their cash has already been maximized.
The real problem faced by potential clients though was highlighted this morning when a consultant surgeon referred to needing an outstanding cash flow “purge” within his practice. This highlights to me a more fundamental underlying issue. Let me explain.
A consultant surgeon – just the same as any business – should know how much he is invoicing both in terms of patient numbers and the value of those patients.
If he is invoicing correctly and ensuring he gets paid he can also, therefore, calculate his revenue receipts.
he wasn’t a consultant surgeon but sold another service or product, he should be able to perform the same calculation.
So he knows how much he is or should be invoicing. Providing he proactively manages his practice.
If you think about it, most consultant surgeons already know their overheads too. They know how much their room rental is. They know how much the staff cost. And they know how much their professional indemnity costs (too much before you ask).
Of course, there are other expenses but fundamentally they already know their expenditure.
know their total costs.
Therefore they know or should know how much they are spending too.
Enter stage left Mr. Micawber:
He knew a thing or two about how to run a private medical practice did Charles Dickens.
For one thing, he knew cash doesn’t just flow into it.
It has to be managed.
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At a recent presentation, I was asked about the costs and use of accounting software. Bearing in mind the presentation was to consultants who had not yet established a private practice, numerous eyebrows were raised when I answered…
You may not need it yet.
This does not mean accounting software is unnecessary, expensive or unsuitable for an established practice. Some private practices do need a software package and there are some fine software packages out there. They are cost efficient too. MHM works, very successfully, with many of them too.
But for those seeing say 10 or 12 patients a week use MS Excel or Apple Numbers and an online diary. MHM has more than a few clients for whom it raises invoices on Excel and uses the same to run a sales/debtors ledger. The invoice can be sent as a PDF attachment to an insurance company. The sales ledger – once password protected – can be sent either to the client and/or the client’s accountant.
If a private practice is a business – and it is – then you MUST keep an eye on all costs. If you do not, profit will reduce.
It’s always useful to ask yourself the question: am I paying for something I don’t actually need?
For a copy of an MHM Excel based sales/debtors ledger go to the Freebies section on this website. The invoice is there too.
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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. Last year, for example, one insurance company 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. In both cases their solution has been problematic. Refusal has often been met with the threat of de-recognition by the insurance company concerned. The act of 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. But what is disturbing when MHM talks to new clients is 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 were happy to pay anyway.
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.
But 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.
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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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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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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.
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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It’s amazing how many people don’t back their IT systems up. When they have an accident, they have a serious accident.
One guy kept all his correspondence and notes on his laptop and only on his laptop. No problem at all until the day his laptop died on him. This specific problem was not resolved of course by him immediately going out and buying new equipment.
All the data was on his now-defunct laptop. Luckily a computer specialist was able to extract the hard drive and more importantly the data on the hard drive. It only then did he consider the implications of the accident that would have followed if the computer specialist had not been able to do that!
One of the first things MHM suggest to new clients is if they don’t have backups to go out buy an external drive and back everything up. MHM equipment is backed up every 15 minutes onto an encrypted offline storage device. Every night the external drive is placed in a fireproof safe. At the weekend the exercise is repeated. MHM clients don’t have to back up any of their invoices and billing correspondence anyway.
Have you considered how you back paper invoices up?
The first thing to ask is why do paper invoices exist in the first place? With the exception of self-funders or an invoice for an excess or shortfall, they shouldn’t. But you’d be surprised at how many consultants still send paper invoices unless the insurance company concerned specifically dictates on-line invoicing only.
A simple solution is available within MHM. All invoices etc are saved as a PDF document and stored in an encrypted format offline.
It’s always better to back up before or in case you have an accident
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The response to a recent question.
Consider if, during the initial consultation, a patient is advised surgery is required. The patient is therefore given a CCSD code equating to the surgical episode to quote to his or her insurance company. Following a conversation between the patient and their insurance company a pre-authorisation code for, as an example, AB1234 is issued to the patient and passed on to the consultant surgeon.
What happens if, during surgery, a change of surgical procedure is deemed necessary? Does it make a difference? Certainly not to the patient and not to the consultant surgeon who has performed what he or she deemed to be the absolutely correct procedure.
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.
And thus MHM invoices the correct fee and you get paid the right fee.
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