Simon Brignall continues last month’s reflection on the challenges groups face with their billing and provides a check list for you to use when considering setting one up.
In last month’s article, we discussed the fundamental differences that consultants find about groups, such as the volume of patients being treated as well as the various structures they adopt in their set-up.
Now it is time to get into the specific challenges groups face with their billing and collection and why it is important to ensure you have the correct processes and infrastructure in place.
Billing and pricing
Because a group consists of a variety of consultants, it is required to manage the various pricing policies used by each specialist.
This can arise either by choice, as a reflection of the consultant’s expertise and experience, but more commonly it is because of the individual contractual terms each consultant is subject to with the private medical insurers.
And that has become more prevalent in recent years with newer consultants restricted to set consultation fees with Bupa and AXA and some of the other insurance companies, while older consultants may have their own tariff or higher contracted fees.
Each consultant can also have their own fee schedule for self-pay patients, although some groups choose to employ a consistent approach.
Some consultants require their self-pay fees to be collected directly from the patient or as part of a fixed-price package and this can vary depending on the hospital or specific procedure.
All this requires the group to maintain accurate records of the price structures and payment pathways used by each consultant.
All this is on top of keeping up to date with the ongoing changes that occur within each insurer’s schedule and the changes to the Clinical Coding Schedule and Development Group (CCSD) schedule to ensure the group is invoicing correctly for each doctor.
In our experience, groups find this area challenging and if it is not done correctly, then we have seen groups that have lost tens of thousands of pounds in income. Always remember that incorrectly invoicing insurance companies leads to delays in payments, recoups and, in the worse cases, derecognition.
Depending on the model the group choses to adopt, there can be different arrangements for payments and bank accounts.
Formalised group structures generally have one pooled bank account or, on rare occasions, individual sub-accounts.
It is important to note that insurance billing is normally processed using the individual consultant’s provider number which will pay into a single designated bank account. Some groups have their own provider number that is shared by all members of the group for billing, but this is rarer.
In each of these examples, each payment needs to be identified and allocated to the appropriate consultant so that any subsequent onward payments can be made to them depending on the group’s revenue distribution model.
Some consultants may also choose to practise outside of the group; however, this requires vigilance and co-operation between the group’s administration team and those servicing the consultant’s external activity.
As discussed earlier, payments can only be made to one designated bank account associated with the provider number and remittance advice can only be sent to one contact point. This means robust procedures need to be adopted to allow for transfer payments and remittance sharing.
Even in those cases where a second bank account is an option, it is common for payments to be made to the wrong account.
In virtual group structures where consultants act as individual practices, payments are made to each practice. But they still require reporting that allows for the recovery of costs for the running of the group.
It can be quite common for us at Medical Billing & Collection (MBC) to take on groups where we find that payments have not been going to the correct bank account and so the group had been missing out on income for years.
It is key to ensure whatever processes you implement that there is good visibility for all stakeholders involved and that reports are both accurate and up to date.
At MBC, we recreate the specific structure the group adopts in our software, which allows for reporting at both the group and the individual consultant level. This provides the group’s management an array of real-time reports at the group level as well as providing each consultant access to their own data.
The trend towards consultants choosing to operate in groups is well established and groups now make up a major share of our activity.
If you are seeking to establish or join a group, this article will act as useful guide to some of the challenges you may face and some of the questions you need to consider. Often the best solution is to seek the advice of a professional medical billing company.
Simon Brignall (right) is director of business development at Medical Billing & Collection