The History of private consultants, clinics and groups is littered with a long history of incorrect billing – and, sadly, it has been getting worse.
At Medical Billing and Collection (MBC) we have recorded many examples of practices getting things wrong over the last 27 years or experiencing some very difficult issues in this field.
But as a result of the many changes to billing processes, combined with the greater administrative workload that busy practices face daily, things are getting a lot tougher for more and more doctors.
Most private consultants are typically running both an NHS and private practice, so they have considerable demands on their time.
On top of this, our data reveals that consultants are working harder to maintain the same income – the average value of the invoices we raise has reduced by 25% over the past ten years.
We have seen how practice secretaries have had to manage a big increase in the volume of communication they receive from patients. In the past five years, this has rocketed.
At the same time, secretaries are organising the clinics and theatres, typing correspondence and managing practice schedules. They then need to try and find the time to raise your medical invoices, reconcile the payments and chase any shortfalls and aged debt.
So we can see that there are many reasons why it is often difficult to ensure that the billing is being done both correctly and in a timely fashion, and also that robust chasing procedures are adhered to.
If your practice does not want to lose money on a continual basis or worse – contravene insurance company regulations and risk being derecognised by them – then it does need to make plans to address this critical area.
Some of the problem areas we see regularly are highlighted below:
CCSD stands for Clinical Coding and Schedule Development and there are over 2,000 CCSD codes covering both consultations and procedures as well as an additional schedule of diagnostic codes.
The CCSD schedule is updated monthly and can include:
- Rules on which codes can be billed together and those which cannot – known as ‘unbundling’;
- The narrative against a specific code;
- Replacement codes;
- Discontinued codes;
- New codes.
Any of the above can cause billing errors, so it is important these updates are reviewed for problems that may impact your practice.
The CCSD schedule is used by the medical insurers as the basis to create their own fee schedule. But this is complicated, as it is not mandatory to follow CCSD rules.
So this means that each insurer can choose to adopt the CCSD schedule in whole or part, resulting in some not recognising specific codes and some having their own rules about which code combinations are acceptable for billing purposes.
Here are the main exceptions:
- Some insurers will only allow certain codes to be billed in conjunction with a follow-up consultation;
- One insurer does not allow a follow-up consultation to be billed within ten days of an operation;
- An insurer can restrict the amount of inpatient care that can be billed by including a set amount within the specific code used in surgery;
- Different rules around the billing of a local anaesthetic.
Due to the above, there are many varied and complex rules regarding the use of the codes and, on top of this, you need to know the pricing schedule for each insurer.
Here are some examples:
- Some have a fee for each CCSD code;
- Some place each CCSD code into different categories for pricing purposes;
- Some do not publish a schedule – they will pay what they consider to be market rate.
The last point to understand is the different coding formulas used by the various insurers. It is dependent upon the number of codes used.
- Example 1
- Some state that if you bill three codes together, then you multiply the highest value code by 40% and then add that figure to the price of the highest-value code;
- Some say that when two codes are used, you multiply the price of the highest-value code by 25% and then add that figure to the highest-value code.
- Example 2
- Some decree that if you bill three codes together, you take the highest-value code and add to that 50% of the second highest-value code; then add 25% of the lowestvalue code to the figure that you have already calculated;
- Some say that when two codes are used, you add 50% of the second highest-value code to the price of the highest value code.
- Example 3
- Some say that when three codes are used, you can only charge for two codes, as they do not recognise the use of three;
- Some insurers state that when two codes are used, you add 50% of the second highest-value code to the price of the highest-value code.
Payments and remittances
It still surprises me how often we come across practices where there are issues around payments and/or remittances.
Let us start with the most important of these two, which is when payments from an insurer are not being sent to the correct bank account.
This can happen for a range of reasons, including when a consultant moves into a group, switches from a sole trader to a limited company or even changes their marital status.
AXA requires that any changes to your bank or contact information must be implemented through the Private Practice Register (PPR).
If you are not already set up on the PPR, then this involves completing an online process that requires uploading supportive documentation. This has meant that some practices have been slow to update their records. At MBC, we routinely confirm that this information is correct as part of our onboarding process.
Remittances are often not being sent to the correct address. This can happen when a consultant moves home or as a result of changes in their place of work or medical secretary.
This results in payments not being reconciled, which can lead to invoices being chased that have already been paid. This is critical for remittances from the insurance companies, as you would not realise that you had to raise an invoice for a shortfall or an excess that had occurred.
Any delay in this important task looks unprofessional from the patient perspective and naturally means that receipt of these funds is delayed.
We find that issues around the billing and chasing of shortfalls are one of the most common issues practices have.
So, as can be seen, it is often a challenge to manage the issues I have outlined and you can now see how a busy practice can have so many difficulties in this area.
The most common errors we see are price-related that impact the total value of an invoice and result in a potential loss of income that may have gone back years.
“WHAT STEPS TO PUT IN PLACE”
- Make sure you understand the complexities of the CCSD schedule for your specialty including what coding combinations can be used
- Make sure that you code correctly by understanding the narrative for each code and review the monthly updates
- Know the formula used by each insurer for pricing multiple codes
- Be aware of the different rules each insurer will have over and above the CCSD schedule
- Make sure that bank details for payment and contact details for remittances are up to date Maintaining all of the above steps can be a daunting task; it is our experience that as the practice continues to grow, the consultant and the secretary are so busy dealing with the medical side of the practice that this area is frequently overlooked. If you are struggling doing all of the above, then you need to consider outsourcing your medical billing and collection, as this specialist knowledge will typically form part of the services provided.