The repetitive nature of the problems private practices experience with their medical billing are revealed by Simon Brignall.
The 1993 film Groundhog Day, starring Bill Murray, depicts Phil Connors as a cynical TV weatherman who visits Punxsutawney in Pennsylvania, US, to cover the annual groundhog festivities.
In the story, he repeats the same day over and over until he learns from the error of his ways.
As director of business development at Civica Medical Billing and Collection for ten years, I’ve had the opportunity to meet hundreds of consultants in private practice and so I’ve been exposed to a wide range of their billing and collection challenges.
Hopefully, my experiences of encountering consultants’ problems means I can pass on what I have learned without you needing to repeat them yourself and experiencing your own groundhog day.
My background is in finance, so when I first started hearing the problems practices were facing, I was constantly surprised at what I came across – and it was soon apparent that these were not isolated cases.
Let me share some of the recurring challenges and, importantly, how you can take steps to mitigate them. As these issues cover a wide range of topics, I will discuss more next month in part two of this article.
One of the first things that struck me when I started to meet with consultants was how many of them did not know their fee structure or specific billing arrangements for the range of patient types the practice treated.
This is not surprising when you appreciate how busy most consultants are, quite often running both an NHS and private practice and managing all the demands this entails. In many cases, this means they rely on their secretary for this information.
One common problem is that this data is not always available in a simple format for anyone involved with the practice billing to refer to if required.
A good example is that I still come across practices applying Bupa procedure fees across the full range of their insured patients. Insurance company fees can vary by as much as 100% for the same procedure, so they have often lost out on thousands of pounds.
Fees for consultations and procedures often vary between each private medical insurer and so making sure the correct fee is used when billing is key.
Some insurance companies allow for an extended consultation to be billed at a different rate in specific circumstances.
It is also important to make sure your practice keeps up to date with the changes in Clinical Coding and Schedule Development group (CCSD) codes for your specialty and the approach each insurer has taken to these changes.
These are updated monthly and changes can include:
- Rules on which codes can be billed together and those which cannot – commonly referred to as ‘unbundling’;
- The narrative against a specific code;
- Replacement codes;
- Discontinued codes;
- New codes.
Most insurers publish a price list detailing what they will pay for each CCSD code. As these vary greatly, you should always check you are billing to the correct tariff.
I have also come across consultants with issues about overbilling the insurers.
This has meant they were either subject to clawbacks, have seen a reduction in the number of patient referrals and, in some extreme cases, have been derecognised by the insurer.
Key person dependency
Key person dependency risk is when one of your employees is solely responsible for something and there is no back-up plan. This means that the subsequent loss of this key individual can have a big impact on your business.
For most practices, the practice manager/medical secretary is the person who manages all the administration.
To expect one person to manage all aspects of the patient’s journey as well as all the billing and collection work is not sustainable, especially as the practice grows. For many busy practices, the first thing to suffer perversely is its finances as patient issues take priority.
Remember, as the practice expands, so does the risk associated with this key individual.
The pandemic highlighted this for many practices, with long-term secretaries choosing to either retire or reduce their working hours.
Often practices are impacted by maternity leave or absenteeism, which means less experienced staff are brought in and often aren’t up to the task.
I have many conversations with consultants where the medical secretary who had been with them for many years retires or leaves and all the knowledge around their billing and collection is lost.
There may even have been a handover with the new replacement secretary, but as the practice has then had a series of secretaries, often through no fault of their own, this information is mislaid or is no longer reliable.
This degradation in expertise around the nuances of a practice can cause a downward spiral to its finances and can often coincide with a deterioration in the service quality the patient experiences.
The simplest and most effective way of resolving this issue is to split the billing task from the patient engagement and other practice administration.
By outsourcing to a medical billing company, you not only gain functionality and expertise in this key area, but it also means your secretary is able to keep their relationship with the patient focused on their clinical needs free from having to broach those challenging conversations about money.
Obviously, it is extremely important to see your work is invoiced in a timely manner. By keeping on top of the invoicing process, this will ensure you have consistent cash flow and you keep debts to a minimum.
There is also the additional benefit that any billing issues are picked up more quickly, which increases the likelihood they can be resolved swiftly. Remember, delays in raising invoices reflects poorly on the professionalism of your practice.
As the raising of an invoice is the first step in the billing process, adherence to this simple rule results in benefits across the whole invoicing and chasing process.
I meet with many practices where this is not happening and they often cite a range of reasons. Here are just a few:
- The consultant has responsibility for the billing but no longer has the time due to an increase in the practice size or additional workload;
- The practice has fallen behind on its billing and chasing and is now daunted by the size of the problem and is unsure how to tackle it;
- Issues related to electronic billing.
There is an increased pressure on consultants due to the adoption of time limits by some insurers. If this is exceeded, it means the invoice is invalid and won’t be paid.
With overseas self-pay patients, it is often preferable to collect payment before treatment or at the very least to have chased for this income before the patient returns home. Once they are abroad, it can be a problem to collect the money.
We collect money up front for most of our practices who see overseas patients.
There can also be a requirement to raise and collect payment up front for UK-based self-pay patients for a range of specialties. We collect payments up front for the procedures for all the plastic surgeons that we partner with, as well as for other specialties with large up-front costs, such as clinics and consultants who work in the fertility field.
As you can see, there are many ways to lose money or suffer from poor cash flow – which is why I continue to have the same ‘groundhog day’ conversations with practices who are struggling.
Next month, I will discuss problems consultants encounter with electronic billing, reconciling and chasing payments and ensuring they have adequate infrastructure.
What I would strongly recommend, meanwhile, if you feel your practice is weak in any area I have outlined or that some of the points I have raised struck a chord, then one of the simplest and most effective solutions is to outsource this vital element to a medical billing and collection company.
Simon Brignall (right) is director of business development at Civica Medical Billing and Collection