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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This blog could easily have been called ‘YOU WON’T UPLIFT A FEE BY DOING THAT”
Recently a private consultant – the colleague of a current client in fact – called me with a problem. Sadly it was a problem very much of their own making!
In an effort to increase fees, the consultant had decided that a surgical episode should be billed as follows: AB1234 £640 and CD2468 £75. So the total fee = £715.00 and on June 1st, 2015 the insurance company was sent an invoice for £715.0. And promptly proceeded to reject it.
The fee for the AB1234 was and still is correct. But with this particular insurance company offering 50% of a second code, the CD2468 fee was wrong to start with. It should not have been £75. It should have been £37.50. Great. Save the invoice would still have been rejected. Why this time?
If the private consultant had checked they would have discovered that this second CD2468 code was deemed by the insurance company to be part and parcel of the AB1234 procedure. Thus it was never going to get paid anyway and it was deemed unbundling to submit an invoice and charge for both items.
Skip forward to September 2015. The consultant – or more accurately his long-suffering secretary – has called, emailed and written to the insurance company because the consultant is still unpaid the £640 for the AB1234.
Hence the phone call to MHM.
For once even I couldn’t do anything about the multi-code element. It very clearly states on the insurance company website that a consultant cannot invoice a CD2468 alongside an AB1234. In fact, it also says so on the CCSD website. It is deemed unbundling to do so. The bottom line is that from June 2015 to September 2015 the consultant has been £640 out of pocket. MHM called the insurance company and has confirmed the original invoice has now been canceled and re-submitted an invoice for an AB1234 £640.00. It is being paid on September 18th too.
Moral of the story?
You will NOT uplift your fee by charging the wrong amount and you most definitely NOT uplift your fee by unbundling.
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If you get the basics right many problems with getting paid aren’t allowed to happen. The basics mean the absolute minimum and mandatory requirements in order to present an account for your services. The basics are as follows:
Patient’s full name
Patient’s full address
Patient’s post code
Patient’s date of birth
Policy number of the insurance company concerned
Pre-authorisation number issued by the insurance company
Correct CCSD code
But it doesn’t stop there.
Your invoice should always have on it:
Your name and address
Your provider number
A unique invoice number
The date of the invoice
The date of the treatment / consultation
The right CCSD code
14 points. But if you don’t get all 14 on your invoices you make it harder for the insurance company to pay you!
If anybody wants a blank invoice that does satisfy ALL the above, go to the freebies tab on this website! If you are billing electronically – and you should be – you’ll still need the vast majority of the 14 points.
But the proof of the pudding is very much in the eating. Have a guess at what are the TWO major reasons an insurnace company does NOT pay your invoice?
1. you haven’t sent one (crazy but true)
2. you haven’t included the right information.
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A 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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A question we were asked very recently. One in fact we are asked frequently!
There are a few very simple reasons why on-line invoices are not being accepted – the details being submitted are incomplete and/or the details being submitted are wrong.
MHM is a big fan of electronic invoicing and uses it wherever and whenever possible. But it does depend totally on one item – absolute correct data. For example: if you try and invoice electronically you will almost certainly be asked to state the patient’s date of birth and the patient’s postcode. If either is incorrect or is missing then you will NOT be able to invoice. This in fact goes back to a consistent requirement of making sure you or your secretary obtains the correct details. Let’s put this in perspective. In 2014, MHM was asked to review the billing of a large private medical practice. The issue was the practice was owed significant amounts of money and could not get paid by one specific insurance company who insisted invoices should be sent electronically. MHM reviewed 100 invoices all of which had failed to be accepted electronically. In well over 60% of the cases either the patient’s policy number was missing or date of birth was missing or the patient’s post code was missing / wrong. The practice manager responsible for this had, to resolve the problem, decreed the invoices should be sent in paper form instead. A clear case of mistaking movement for action! The insurance company concerned, remember, had stated invoices should be sent electronically and ONLY electronically.
There is no such thing as a quick fix to this. Indeed a quick fix – such as sending invoices in paper form instead – often leads to even more problems as it does not resolve the cause of the issue.
MHM suggested going forward ALL patient details were captured correctly and the data verified with NO exceptions. We then took the “old” invoices and corrected / completed the data.
Within 4 months the average monthly cash flow into the practice had increased from around £120k a month to £260k a month.
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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!
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.
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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A couple of examples recently where consultants who have tried to base their fees on the best rate available. Take the consultant who realises that PMI company Num 1 pay £300 for a procedure whereas PMI company 2 pay £400. He decrees he will charge PMI Company 1 the PMI Company 2 rate.
Great idea. Right up to the point PMI company 1 receives the invoice for the higher amount. They will decline to pay that fee. Most likely they will shortfall it. But, replies the Consultant, no problem. The patient is ultimately liable for any shortfall. I know of one consultant who even puts on his website “we use PMI Company 2 rates to calculate our fees and therefore there may be a shortfall which you will have to pay”
Yes, the patient is liable for a shortfall BUT not when the consultant is fee assured he isn’t.
Most likely a letter addressed to the Consultant will arrive sooner or later from PMI Company 1 pointing out that such “inappropriate billing” is not acceptable; carry on doing it and recognition is at risk.
It’s incredibly 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.
Notwithstanding the above, of course, consultants want the best possible fee for a procedure but attempting to obtain the same by “inappropriate billing” is not the smartest way to go about it.
Read more →