As a natural practitioner, understanding the ins and outs of insurance can be important and really help broaden access to your services. Determining whether insurance is a viable option for your practice and can make a big difference in your cash flow and practice livelihood. So, let’s dive into how you can navigate this complex world. In particular, the differences between in-network vs. out-of-network insurance and how you should optimize between them.
In fact, in a Soundry survey conducted in February 2022, a large percentage of integrative providers are actually part of insurance networks. In fact, 76 percent of them are in-network with at least one carrier, and 15 percent accept both in-network and out-of-network patients. However, let’s break down the options a bit, because it is important to not decide to take insurance but to consider the strategies and approaches on how to do so.
What is in-network insurance? Participating in-network with an insurance company means that you’ve negotiated a contract with the insurance payer and established specific rates with them. The biggest benefit is also that you are an approved in-network provider on insurance payers’ platforms. Being in-network offers certain advantages: it can translate into a steady influx of new patients, pivotal for practice expansion, and can facilitate referrals from other medical practitioners.
Nevertheless, in-network participation does have drawbacks. Managing insurance billing can prove to be a time-intensive and intricate endeavor, replete with administrative intricacies. And the often long process of becoming an in-network provider entails navigating through tedious paperwork and credentialing requisites. Furthermore, once in contract with the network, there is no leeway for negotiating payment rates. So while you may have a higher volume of patients, they might be reimbursed lower on a per patient basis. However, don’t forget that these new patients can become longer-term recurring patients that can then transition to other forms of payment or other services that aren’t covered under insurance. This can ultimately still help you build your practice successfully and we find that often providers looking to build a practice start with in-network participation.
In Network
Should you opt for in-network participation, make sure you keep on top of administrative tasks. First of all, maintain meticulous records of your contracts to ensure adherence to agreed-upon payment terms. Periodically take a look at how long you’ve had your contracts. As inflation increases and cost of living changes, you might need to renegotiate your rates. We recommend looking at the data every two to three years to see if you should renegotiate.
When renegotiating contracts, arm yourself with comprehensive information: engage with peers in your area, determine the density of neighboring natural practitioners, and try to assess whether you offer any unique services within your area. If it has been a while since your last rate negotiation, scrutinize fluctuations in the cost of living during the interim period, utilizing such variations to justify your plea for commensurately elevated rates.
Out of Network
In contrast, out-of-network participation also offers its own merits. Out-of-network practitioners operate without a direct contractual tie to the insurance payer. Out-of-network providers typically benefit from higher reimbursement rates, and obviate the need for a credentialing process, although some insurance payers still require registration as an out-of-network provider on their platforms. Additionally, out-of-network practitioners enjoy greater flexibility in the billing process, with the option to either levy self-pay rates and furnish a superbill for patient-initiated insurance claims or submit claims on behalf of the patient, coupled with a discounted rate.
Nevertheless, out-of-network engagement entails challenges. There are typically higher deductibles for out-of-network services and higher out-of-pocket ceilings. Thus, patients may encounter more financial impediments. Moreover, out-of-network practitioners might encounter more limitations on session quotas and fee structures, contingent on the insurance payer. Further complicating matters, out-of-network payments and checks may be sent directly to the patient, which requires either running after the patient for the checks or putting in place a financial agreement.
To maximize your out-of-network involvement, make sure you are doing a few things. First, rigorous benefit verifications are imperative, given the number of eligibility check inaccuracies that cost claim rejections. Given that deductibles often soar for out-of-network patients, a comprehensive and detailed understanding of the deductible balance is important, and then subsequently making sure to then work with the patient on the payment plan. Note that insurance payer’s online portals frequently lag in furnishing updated information on deductible balances, session caps or referral prerequisites. So it is best to call the insurance payer directly for this information.
Should you elect to operate out-of-network, consider balance billing. This entails filing an out-of-network claim on behalf of the patient (versus just providing them a super bill that they have to file with the insurance payer themselves), and invoicing the patient for the balance beyond insurance coverage. Such an approach can markedly enhance the patient experience and payment expediency. We have seen that practitioners who adopt balance billing often have better patient retention rates and recurring visits.
As our survey data showed, most providers adopt a mix of in-network, out-of-network and cash in their practice. Typically, the evolution is that as practitioners are trying to build their business, they start with credentialing with many in-network insurance payers. Then as they build their business, they start to understand what insurance is more prevalent amongst their patient base and which insurance providers offer the best reimbursement rates for their particular services or allow for better accessibility. Over time, they then keep in-network with only a handful of insurance payers but continue to offer out-of-network administration for certain recurring patients and move the rest for cash pay.
Ultimately, it is important to understand what insurance can do for your practice before discounting the whole process. By doing so, you’ll have more choices for practice growth and also provide pathways for providing more accessible care to patients.
Tina Hsiao is the COO of Soundry Health. Soundry is focused on delivering an all-in-one insurance billing service and EHR for integrative practitioners. Prior to joining Soundry, Hsiao was chief operating officer of WePay. She has also scaled and launched several businesses at Intuit and QuickBooks. Hsiao graduated from Columbia University with a BA and an MBA from Harvard Business School. For more information, visit www.soundryhealth.com.
