How do groups go about their medical billing?

Group practices can face real challenges when setting up their billing. So leveraging the experience of others, is a smart strategy to use.

Billing and pricing

Groups consists of a variety of consultants and therefore need 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 because of the individual contractual terms each consultant is subject to with the private medical insurers. In recent years this has become more common with newer consultants restricted to set consultation fees with Bupa and AXA and some of the other insurance companies, while older consultants 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 complexity requires the group to maintain accurate records of the price structures and payment pathways used by each consultant.

This is on top of keeping up to date with ongoing changes 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. Incorrectly invoicing insurance companies leads to delays in payments, recoups and, in the worse cases, derecognition.

In our experience, groups find this area challenging. If it is not done correctly, then groups can lose tens of thousands of pounds in income.

Bank accounts

Depending on the group model, 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 also practise outside of the group; however, this requires extra vigilance and co-operation between the group’s administration team and those servicing the consultant’s external activity.

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.

Reporting

It is key to ensure whatever processes you implement there is good visibility for all stakeholders and that reports are both accurate and up to date.

We recreate the specific group structure in our software, which allows for reporting at both the group and the individual consultant level. This provides the group’s management with real-time reports at the group level as well as providing each consultant secure access to their own data.

8 questions to ask if you are considering joining a group

1. What group structure have they employed and is it right for me?
2. What are their costs and how are they allocated?
3. How are funds distributed to each group member?
   • Are finds collected centrally?
   • Are there any specific rules that relate to founding partners and new entrants?
   • Ensure you understand whether funds are distributed out of received income and when you can expect these payments to be made once received by the group.
4. How is the administration of the group managed?
   • What is the impact to this should the group shrink or expand?
5. Does the group use practice management software?
   • If yes, is the reporting available to you? How easy is this to do and is the data accurate and up to date?
   • If no, then what systems do they have to provide you with the information above?
   • Are there any issues with whichever system they use?
6. What is the current state of the group’s finances?
   • Pay specific attention to any delays in invoicing and the size of the group’s aged and bad debts, as this will impact your cash flow.
7. Does the group accommodate bespoke pricing?
   • How often are fees and CCSD codes reviewed to ensure any relevant changes are applied and opportunities not missed?
8. Will the group accommodate all your private activity?
   • If not, how will the remaining activity be invoiced?
   • What will be the implication for payments and reporting?

Find out more about Civica’s Medical Billing and Collection service.

This article was originally produced for Independent Practitioner Today.