Ensure you get paid

In the first of two articles, Simon Brignall discusses five common themes arising from his conversations with consultants wanting to address their issues around medical billing and collection

THE PANDEMIC has resulted in a backlog of patients who are now seeking to access private health­ care about medical issues that should have been addressed earlier but, for one reason or another, they had deferred.

Many consultants similarly have delayed decisions about private practice. This has included new consultants seeking to start out in private practice or those estab­lished independent practitioners who are looking to expand or con­centrate fully on private work.

Not all the delays can be attrib­uted to consultants; for example, one UK insurance company was not open to new applicants for nearly six months. This resulted in a bottleneck of new consultants in the first half of the year.

This has meant that I have spent the past few months fielding inquiries from consultants, groups and clinics with questions about medical billing.

I have observed that many of the conversations have tended to focus on the same issues and so I thought it would be beneficial to examine the key ones.

There are ten main billing issues to address in many private prac­tices. I will deal with the first five in this issue of Independent Practitioner Today and the remain­der next month.

1. Terms and conditions

This has always been an important area, but it is very rarely managed correctly in a private practice.

With the advent of the Comp­etition and Markets Authority stipulations regarding pricing, Private Healthcare Informa­tion Network transparency require­ments as well as adherence to the General Data Protection Regul­ations, this is now even more important than ever.

“If the terms and conditions are clear, then the payments process is improved and there is a point of reference to resolve any disputes”

You need to have your terms and conditions (T&Cs) documented and presented to the patient prior to any treatment taking place.

This would typically take place on a ‘patient registration form’ or as part of the initial correspond­ence when a patient engages with the practice. Areas covered include pricing, insurance short­ falls and any payment terms appli­cable, plus consequences if the patient fails to attend their appointment.

It is important to stipulate that the patient is liable for all the costs of their treatment, including any costs that are not covered in full by their private medical insurer. If the T&Cs are clear, then the payments process is improved and there is a point of reference to resolve any disputes.

2. Infrastructure

I often meet with consult­ants working in private practice who operate their billing process either manually or on a word pro­cessing diary and spreadsheet plat­form.

I have seen a range of manual solutions including notebooks detailing money owed and all sorts of Kafkaesque filing cabinet solutions.

A few years back, I had a new cli­ent where the handover consisted of being passed carrier bags containing invoices, unbilled clinic
lists and unreconciled insurance remittances.

Even when these practices use some form of software programme to control their billing system, more often than not these soft­ware programmes are run on lap­ tops, notebooks and personal computers which are not backed up.

This is far from ideal from a busi­ness recovery perspective, because if the device is lost or the software becomes corrupt or the hardware fails, then the consultant’s recordkeeping and finances are put at risk – with all that this entails.

When commencing private practice, one of the first things doctors should do is to ensure their set-up is run on a sound financial basis with the appropri­ate infrastructure.

A vital element of this would involve having a robust auditable system to facilitate the financial processes of the practice. This should include the ability to:

  • Raise invoices;
  • Reconcile payments;
  • Employ a robust chase process, including the ability to follow up on outstanding invoices using a range of communication meth­ods.

Irrespective of what system is chosen, it is important to ensure it is backed up daily to provide financial integrity and conform to best practice.

If you are already in private prac­tice, but currently do not have the appropriate infrastructure in place, then I recommend you put it at the top of your list of action points. This is because the risk you.

“Our experience is that consultants typically do not set their prices effectively because they have not done enough research when initially conducting this exercise”

run is growing every day that this is not addressed.

3. Pricing

I know from experience that pricing has always been the area that appears to give consultants the most stress. The reason for this is that it is a very difficult area, both within the insurance market as well as the self-pay sector.

Firstly, the consultant must decide, where they have the con­tractual option, whether they are going to adhere to each private medical insurance (PMI) compa­ny’s price schedule. Secondly, they must know the individual price schedule for each PMI, as each has their own specific price for each code.

There are over 2,000 codes pro­vided by the Clinical Coding and Schedule Development group (CCSD), and some prices can differ by up to 100% between PMIs.

On top of this, each consultant must decide what rate they are going to charge for their consulta­tion fees. In some cases, the con­ tract the consultant has signed with the insurer will dictate what rate they can charge for both the procedure codes and the consulta­tion fees.

Where the consultant is not contractually restricted, then they need to determine their fee struc­ture and this is also the case for all fees related to self-pay patients.

These decisions are often made with minimal information, as quite often the consultant will find that while their peers will share medical knowledge, they are less likely to share commercial information.

If the consultant gets this area wrong, it can lead to them being incorrectly priced within the mar­ket and so they lose patients because their pricing is too high, or worse they lose thousands of pounds due to their pricing being too low.

Our experience is that consult­ants typically do not set their prices effectively because they have not done enough research when initially conducting this exercise.

Fee structures are often not rou­tinely reviewed. Many consultants who tell me it has been over a decade since they last looked at their fees!


Once a consult ant has decided on their pricing policy, they need to ensure they keep abreast of all the CCSD changes to the codes that are applicable to their specialty.

Changes to the coding sched­ ules are implemented monthly. There can be replacement codes, new codes, changes to descrip­tions and the ability to bill multi­ple codes together.

All of this can also impact on what can be charged to each insurer. Lack of knowledge in this area can often lead to undercharg­ing for procedures or billing prob­lems with the PMIs that can delay payment.

Continuing to incorrectly invoice insurers can result in puni­tive action in extreme cases.

5. Speed

It is important that a prac­tice raises their invoices promptly; however, it is not uncommon for the practice to delay this function by weeks and months.

The longest delay I have seen was with a surgeon who had not raised an invoice for over two years and the size of the problem had meant the practice had become paralysed in addressing the issue.

So why does practice invoicing fall behind? There can be a range of reasons:

    • Consultants who invoice themselves often prioritise seeing patients and other work commit­ments;
    • Support staff can find that other administrative tasks get in the way. This can especially be the case in busy practices;
    • Holiday and sickness absences.

Whatever the reason, this can­ not be allowed to happen. Not only does it reflect badly on the practice, which can negatively impact the patients view of their treatment, but it also means the practice’s cash flow suffers.

Remember, the longer the delay in raising an invoice, the greater the risk it results in a bad debt.

Some insurance companies now have strict time limits – typically six months – in which they need to receive an invoice otherwise they will not pay. Effectively, you could end up treating these patients for free.

Another advantage of invoicing promptly is that you will be aware of any issues that may arise, which often improve your chances of these being resolved.

As a good rule of thumb, the practice should set the goal of bill­ing within 24 hours of any treat­ment carried out, as this will ensure good cash flow and mini­mise bad debts.

In next month’s article, I will cover the remaining five billing topics. But, in the meantime, you may want to start addressing the billing aspects I have covered here.

But, of course, often the best solution is to contact a medical billing and collection company that has years of experience in this field.

Simon Brignall is director of business development for Medical Billing and Collection