Healthcare & Telemedicine

Healthcare revenue doesn’t travel well by default. One appointment can involve a telemedicine platform billing in EUR, a clinician licensed in the UK but treating a patient in the UAE, a diagnostics partner in India, and a payer adjudicating from the U.S.—with each party expecting different codes, currencies, rails, and proof. Finance wins when three pieces are explicit and systemized: how charges are constructed and routed (coding, benefit design, prior auth), how and when providers are paid (fee schedules, withholds, clawbacks), and how money and data are partitioned across jurisdictions. Do that and DSO tightens, refunds stop spiraling into disputes, and audits become a scheduled chore instead of a fire drill.

The money map: who pays whom and on which clock

Think in ledgers, not in departments.

• Patient ledger. Self-pay or cost sharing (copay/coinsurance/deductible) collected at booking or post-claim. For virtual care, pre-authorize at scheduling with a soft capture that finalizes when CPT/HCPCS equivalents and units are known.
• Payer ledger. Commercial insurer, public payer, TPA, or corporate benefit plan. Claims are priced via fee schedules and plan rules; the payer returns allowed amount, patient responsibility, denials, and remark codes.
• Provider ledger. Employed clinicians (salary + RVU incentives) and independent contractors (per-encounter/slot). Diagnostics and pharmacy partners add separate settlement streams tied to orders and results.
• Platform ledger. If you aggregate clinics or run a marketplace, you hold funds and split them: platform fee, provider share, ancillaries, tax, and refunds; safeguarding and licensing rules apply if you control timing.

Route each encounter into these ledgers at the moment of booking. If you attach money logic after care is delivered, you’ll be back-solving month-end with spreadsheets and guesswork.

Pricing and coding that won’t melt in cross-border flows

Charges are math, not prose. A clean design carries:

• Catalog of services with crosswalks (e.g., CPT/HCPCS/LOINC/SNOMED where applicable) and country-specific codes so payers recognize the service regardless of origin.
• Place-of-service and modality flags (video, chat, store-and-forward) because many payers price virtual care differently.
• Fee schedules by payer and country: base rate, modifiers, bundling/unbundling rules, and telehealth parity policies where they exist.
• Prior authorization state attached to the encounter (approved/waived/required). For self-pay, the same object holds package pricing and refund terms.
• Currency of account per legal entity and display currency for patients; banded rounding per currency (no CHF 99.07 invoices), and a declared rate-lock policy (lock at capture; reuse for adjusted bills inside a short window).

With these in place, claims price deterministically, and self-pay invoices don’t need bespoke review.

Collecting from patients without turning support into collections

Virtual care thrives when patient payments feel like normal ecommerce but behave like regulated finance.

• At booking: pre-authorize the estimate (copay or package price). If payer adjudication later increases patient responsibility, trigger an in-app top-up with clear explanation and receipt.
• Rails: cards and wallets for speed; account-to-account rails (SEPA Instant, Faster Payments, Pix, U.S. ACH/Same-Day equivalents) for higher tickets and subscription-like programs (chronic care, mental health packages).
• Refund posture: return to original method by default; partial refunds tied to cancelled slots or unrendered components (e.g., kit not shipped). Instant rails cut “where is my refund?” tickets dramatically.
• Descriptor hygiene: clinic/brand + “telemedicine” + city; unclear descriptors drive friendly fraud.

Track cost per successful collection (rail + acquirer + FX + ops minutes) and time-to-refund; they predict NPS better than any slogan.

Payer claims: getting from charge to allowed amount

Cross-border adjudication adds friction; reduce it with structure.

• Eligibility & benefits check at scheduling, not after the visit; cache plan details (telehealth coverage, out-of-network rules, prior-auth triggers).
• Clean claim engine that builds 837-style/EDIFACT or country-native messages with diagnosis, procedure, place of service, modifiers, and referring/ordering identifiers as required.
• Remark/denial taxonomy: map payer reason codes to internal categories (missing auth, not covered, bundling edit, medical necessity). Each category has an owner and SLA (appeal, correct & resubmit, bill patient).
• Currency & rate locks: when a payer settles in their home currency, store lock metadata at EOB—rate, source, timestamp—so FX variance at posting is arithmetic, not debate.

Aim for first-pass acceptance above 90% on mature mixes and keep days to remit in single digits for electronic payers.

Paying providers: fee splits, withholds, and clawbacks

Cash to clinicians is where trust is won or lost.

• Comp models: employed (base + RVU/encounter incentive) and contractor (per slot/encounter, specialty differential, after-hours premium).
• Settlement cadence: weekly/biweekly for contractors, monthly for employees’ incentives; ensure negative balances can net against future earnings without pushing a clinician underwater.
• Withholds & clawbacks: where payers reserve the right to recoup (retro denials, eligibility errors), keep a small rolling reserve per clinician or program; publish release rules by age.
• Rails: pay on local account-to-account rails whenever possible; wires for high values or exotic corridors. Always verify beneficiary (name-match/CoP) to minimize failed payouts.

Post a statement that decomposes gross charges, payer reductions, patient collections, platform fee, taxes, withholds, and net. Ambiguity here creates attrition.

Telemedicine marketplaces and split funds

If you intermediate between patients, clinicians, and labs/pharmacies, you’re a marketplace with licensure and safeguarding overhead.

• Safeguarded accounts per regime where client money rules apply; don’t co-mingle operating cash with patient funds.
• Split payments: at the moment a package is purchased, pre-allocate platform fee, clinician share, and third-party services; release each on objective events (encounter completed, kit scanned, result released).
• Virtual accounts/IBANs per clinic or cohort so inbound bank transfers auto-segment, raising auto-match above 98% by count.
• Tax treatment varies: your fee vs. clinician’s service may have different VAT/GST rules; encode per jurisdiction and line type.

Cross-border prescriptions, diagnostics, and ancillaries

Ancillary flows multiply payment paths.

• Diagnostics: order acceptance + sample receipt + result release = cash milestones. Partner invoices arrive in local currency; prefer local rails and natural hedging where possible.
• Pharmacy: eRx acceptance triggers a separate ledger line; if you’re the merchant, pick instant rails for refunds on substitutions/out-of-stock; if you’re a facilitator, mirror the pharmacy’s settlement and reconciliation data.
• Medical devices/kits: ship/receive logic with serials; refund on unopened returns; partial credits for consumables. Cross-border returns need the right customs codes (repair/return or returned goods relief equivalents).

FX and treasury for multi-currency care

Volatility lives in tails: authorizations today, adjudications and refunds weeks later.

• Natural hedge first: collect and spend locally (clinician payouts, labs, couriers, support staff) to reduce conversion.
• Rate locks at instruction: fix FX when you submit a payout or post a payer EOB; reuse the lock for corrections inside a short window.
• Rolling forwards: cover predictable net outflows one to three months out; avoid 100% single-day rolls.
• Buffers: small per-currency buffers in high-velocity wallets to absorb weekends and bank holidays.

Report FX cost as basis points of clinical GMV and of net payouts; split realized vs translation, covered vs uncovered.

Data segregation and evidence, without turning ops into lawyers

Finance needs proof; regulators need boundaries.

• Segregate PHI/clinical data from finance data; finance stores only the minimum identifiers needed to reconcile (encounter ID, date, service code, amount).
• Residency & access controls: EU/UK data stay in-region; mirror this in reporting so finance exports don’t leak personal data across borders.
• Evidence packs assemble automatically: eligibility check, consent logs, encounter time/place, codes, prior auth, payer response, patient communications, refund approvals.

When payers audit or patients dispute, one click should produce artifacts; hunting through EHR screens at month-end is how write-offs happen.

Fraud and abuse patterns you can actually blunt

Most leakage isn’t exotic; it’s predictable.

• Double-billing & upcoding: code audits on outlier patterns; nudge clinicians with documentation prompts before submission.
• Phantom encounters: require presence signals (video session logs, device pings) for time-based codes.
• Stolen identities & friendly fraud: strong descriptors, SCA where applicable, device/IP coherence, and refund-to-original-method rules.
• Provider payout fraud: no payout to a changed bank account without out-of-band verification and a cool-off; dual control on beneficiary changes and releases.

Reconciliation and metrics that predict margin

Make money self-describing.

• Store amounts as integer minor units + ISO currency; stamp rate, source, timestamp and an idempotency key on every monetary event.
• Ingest ISO 20022 statements; use virtual accounts for clinics/partners; classify variances (FX drift, fee mismatch, payer short-landing, partial pay, duplicate prevention).
• Aim for 98%+ auto-match by count, 95%+ by value, and low double-digit minutes per 1,000 transactions in manual touch.

Watch the dials that actually move cash:

• First-pass claim acceptance; days-to-remit; denial rate by category and recovery rate.
• Patient collection rate and time-to-refund by rail.
• Provider payout punctuality and failure rate (name mismatch, closed account).
• FX cost in bps; hedge coverage vs policy.
• Auto-reconciliation rate; exception aging; share of encounters with missing prior auth where required.

Where a payment intermediary helps

If you operate in many corridors and need multi-currency accounts, virtual IBAN segmentation by clinic or partner, and local account-to-account rails for both patient collections and provider payouts—without engineering a dozen bank connections—bring in a specialist. A provider like Collect&Pay can add corridor coverage, deterministic remittance, and line-level fee/FX transparency that keeps your close calm and your audits short.