The Case For Being In Network
by AJ Riviezzo
Overall I have seen a number of practices transition from a pure cash pay model to accepting insurance. Those that had good assistance in billing, coding, authorizations and documentation requirements were able to make the change in good order. They have seen an increase in patient volume and in total receipts. Yes, their costs did increase but the increase in cash flow was at a faster pace than the direct costs involved.
Another scenario we are asked to discuss with phlebology practices is whether or not they should be in network with the several payers and with Medicare. The positive elements for not taking insurance, they hope, will outweigh the negatives. As such, here’s a quick compare.
No Insurance – Pro’s.
• Cash payments are certainly faster and much easier to obtain/process.
• You do not have to abide by ever increasing and maddening rules and regulations promulgated by Medicare and the commercial payers.
• Staffing patterns are lower because you are not having to pay for billing/collection services or for an authorization coordinator.
• The risk of a government (Medicare audit) trying to shut down your practice is virtually nil.
No Insurance – Con’s.
• Not that many pure cash patients
• If patient pays you cash and then files to their insurance, you may still have to follow the Medicare and commercial rules and regulations
• If any of your patients submit their claims to Medicare, Medicare can still reach in and perform an audit. And, because you may not be fully in compliance with their guidelines, the audit could be problematic.
Insurance Pro’s
• The patient is responsible for some of the care dollars but the majority of it is typically paid by their insurance plan. This should result in a higher volume of patients.
• Patients will steer towards an in network, participating provider and will typically avoid an out-of-network provider particularly since the payers incentivize the patient to do so.
• When treating a pure cash patient, you typically do so on a ‘case rate’ which includes all pre and post ablation care. When working with insurance you should bill for every single service provided as appropriate. Overall, the income per ablation may actually be higher with insurance versus the case rate.
• Your competition is taking insurance.
• Easier to market to the primary care physicians if you are on the same plans they are on. Technically the PCP’s are only supposed to refer to in-network physicians.
Insurance Con’s
• Maddening rules. Delays in payment. Appeals and denials and delays oh my!
• Cost to the practice is higher. You really do need someone who can very competently bill/collect on your behalf. You also need someone who, at least part time, is performing authorizations.
• Contractually obligated to collect patient monies owed for deductibles, copayments and coinsurance.
• Obtaining contracts can be difficult in some market areas.
Overall I have seen a number of practices transition from a pure cash pay model to accepting insurance. Those that had good assistance in billing, coding, authorizations and documentation requirements were able to make the change in good order. They have seen an increase in patient volume and in total receipts. Yes, their costs did increase but the increase in cash flow was at a faster pace than the direct costs involved.
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