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The Pros and Cons of Joining an Insurance Plan



Hey, should I join this plan?  Is it worth it? What are the good ones? Which are the bad ones?

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

All right everyone, and welcome to another edition of To The Point with the American Acupuncture Council, and thank you to the American Acupuncture Council for this opportunity, but also as an opportunity for you to get more information about how to make sure you can run a well run, well-rounded practice, one that you enjoy doing, one that can also be profitable.

On today’s topic, what I’d like to discuss is manage care, joining an insurance. Let’s go to the slides. Let’s talk a little bit about that. Cause it’s a very common question I get as a coding and billing expert and doing this for a number of years with seminars, one of the main questions I get for members is, Hey, should I join this plan?

Is it worth it? What are the good ones? Which are the bad ones? And what I wanna do with this is try to give you a little bit of a primer on what you should do or understand when you join or think of joining, what are the things that you must consider? So managed care plans, I like to think. Is it worth it?

Is there a value to join or not to join, if you will, is the question. So let’s focus in, Let’s really talk about what we mean by the term managed care. Often, I think we misunderstand it, but in many ways managed care just means that the insurance company is truly managing the providers you’re joining.

And you’ll often hear these terms like a preferred provider or a member provider. And these are often what we call ppo, preferred provider organizations or HMOs. And these are plans that the patient is given incentive. To see the doctors within the plan, generally with lesser copays, deductibles, or within hmo.

Of course, it means if they go someplace that’s not in the hmo, there’s literally no benefits, so we have to look whether or not this is worth it. So here it says, insurance plans that provide or that have the provider acupunctures to join in order to gain access to get the insurance payment. Sometimes remember, You can be outta network, and this is one of the things to consider.

Do you have to join an insurance to be paid by it? And let’s make this clear on a regular insurance plan. Once you are licensed, you may bill and access benefits. Unless the plan has a provision that they only pay for providers in network. Be very careful. A lot of people when they first start will think, Ooh, I have to join.

In order to gain access and you don’t. So first thing is make sure, does the plan have benefits that are out of network? Meaning any willing provider or do they require in network by example? Some of you’ve probably have seen these Medicare Advantage plans, Part C plans. They’re advertised quite heavily right now.

Pay attention to on television commercials, and you’ll see companies like United and Cigna and others advertising that there’s acupuncture benefit. Bear in mind, many of these plans don’t require that you join as a provider. Just be willing to accept the patient. Now, when you do accept the patient, you’re gonna be limited to their fee schedule, but at least that way gains access without joining.

Now, the other side would be, if I join, would it be more likely for the patient to come to me? Does it incentivize them enough to choose me as the provider? So again, the provider gains access. But we have to make sure, is that access we could have already had. The real issue here, I think that we want to consider is your business is that it’s a business.

I know it’s a practice and you’re there to help and all do all the good things to care for someone, but at the end of the day, it’s still a business. So like with any business, we have to make a business decision on this type of plan. There is a trade off. What is the trade off? The trade off is if you join, you gain access.

In other words, the patient has incentive to see you. Now, for me, the big issue is does the patient have complete access or is it one that they could still go anywhere? So the bottom line though, it gives you access. It allows the patient to come and see you and have a benefit. And let’s face it, people who have insurance are more likely to go to the doctor than those that don’t.

I’m sure you’ve all witnessed that. You all probably know someone right now, maybe even a family member that needs to go to the doctor but is not going because affordability, they have no insurance, no benefits. They’re not going. So this often is why people with insurance generally go to the doctor more because frankly they have access.

Always think of what’s the barrier to care. Often money. So this may help with that. However, talking about money, the trade off is yes, you may get more patients or at least more access. , But do you get paid? You’re saying money. No, you don’t. Mostly, and I’ll say every time you join a plan, there’s always a reduced or limited reimbursement you can collect.

Now, that reimbursement could be decent enough that it’s worth it, but it may be too low. So one of the things to consider is there enough value for me to do it? In other words, the choices can, the volume. Make up the difference, and in some ways, think of managed care, and this sounds awful, but Managed Care, in my opinion, in some ways is the 99 cents store.

The 99 cents store is a very popular store, but how does that store really function? They have to sell a very high volume of goods because they’re only 99 cents. So you have to think of it when you’re getting reduced payment. Your volume has to go up. Now, this is something that’s a little more complicated for an acupuncturist.

Say, compared to a chiropractor, you have to provide all the services that you deliver in a acupuncture, excuse me, in a chiropractic or physical therapy setting, they can have assistance. Acupuncturists are pretty much out of the loop on that, so it means, for the most part, you have to do everything, all the care, and of course, your care is very time.

I. , Let’s face it. Each set of needles is 15 minutes. And while the eight minute rule does apply, even if you’re doing three units, you’re spending close to 40 minutes, maybe 45 minutes with that patient in your. That’s a lot of time if you’re only getting a very minimal amount of reimbursement. So you’ve really gotta kinda weigh out the pluses and minuses.

And what I think you should do is start to really to look at these plans from a true business standpoint. Like just when you take your first business course in college, one of the things you learn is, Hey, can you make a widget? How much does it cost to make the widget? How much can you sell it for? And how many can you sell?

That depends on how profitable the business can be. So what I’d like you to do is keep it relatively simple. Get a piece of paper, draw a line down the center on one side, put yes, one side, put no, this is exactly what I do with my network members. It can be a little bit more detailed. Obviously in this form we’re limited, but this can give you a good starting point.

Am I gonna join something? The yes would be if it’s exclusive. If the patient has no benefits at. Without you being in the plan. To me, that’s a big yes to join because otherwise there’s no access. What if you’re in an area where there’s a group where a lot of people in your area belong to it?

Would you likely wanna join? Because if they can’t come to you with their insurance, are they still gonna come in or are they gonna choose elsewhere? So an exclusive plan to me is a big yes. However, keep in mind, what if it’s non exclusive? And be careful. A lot of PPOs prefer provider organiz. Are not actually as exclusive as people think.

An HMO is one where the patient has to go within the plan, but a PPO is one where the patient can still choose to go outside of it, and you want to check to see if I join, could the patient still come to me? One of the things I will be concerned with is often people join these plans and all of a sudden realize, Hey, I’m getting less money.

I’ll give an example. Sigma Insurance has done this. There’s a group with a SH that if you join. You get a limited reimbursement, but if you’re out of network, your reimbursement’s the same but or is higher actually. So from that standpoint, often you really wanna look to see if it’s not exclusive, what type of access does a patient have?

And here’s another example. United Healthcare generally will pay providers better that are out of network. And you’re thinking that doesn’t make sense. That’s how the plan works. It just pays more. Now, the difference could be though, maybe they don’t find you because you’re not in the network, or sometimes their deductible could be higher for out of network providers.

So I look first, if the patient could come to me anyway, what’s the incentive here? So you have to look at what’s the balance and how’s it gonna draw someone in, because at the end of the day, it comes down to if I’m gonna join, even if it’s exclusive, is the pay reason. Does it pay me enough to really make it work?

Bear in mind, there are some plans for acupuncture that I kid you not pay as little as about $40 per visit, and that’s all inclusive. I don’t care what you do, you can do five sets of needles in a therapy or two sets of needles. You’re still getting, the $40. And also keep in mind, this is something that surprised someone the other day.

They had a plan that pays 63 42 with a $25 copay. And they had the mindset that the plan was gonna pay 63 42, and then you charge the patient 25 on top of it thinking they were gonna get close to $90. The reality is, in a plan like that, when it says it pays 63 42 with a $25 copay, they’re going to allow 63, 42 minus the 25 that the patient pays.

So the total you. Is 63 42 with 25 of it coming from the patient. So we have to look even at that amount. Is that reasonable? Is it enough for me to really make my office work? What if it just simply pays too little? know, You look and go, I can’t do that. Work for it. You know yourself as a practitioner, some of you could spend maybe 20, 30 minutes with a patient.

Some of you might spend an hour or. The more time you spend, the more value to the service. You can’t really survive. If you’re seeing a patient for 40 bucks and spending an hour or plus, I don’t think you can keep your practice helping. Let’s face it, that means you can make a max of maybe 300 a day, and I’m not sure $300 a day is gonna keep enough for your office as well as your home expenses.

The other fact to think of though is what if I joined? Does it bring me many new patients? Would it give me access to people who otherwise wouldn’t? That’s something to consider. What if all of a sudden you can get many more patients? Realize if an increase in volume happens, then that could still increase the bottom line cuz you’re seeing more people.

The limitation as an acupuncturist though, is how many people can I see per day? There’s limits there. There’s only so much time in the day. If you spend an hour with every patient, all you can see is eight and eight hour day anyway. So something to think of. But if it brings a new patient, I think.

That’s not a bad thing. You know what? If this is a new patient that you wouldn’t I otherwise see? And bear in mind, I had an office once that said, Sam, I’ve joined these plans because when I join, these people come in. But they often refer me people that aren’t part of the managed care plan because they have friends.

And so I thought, Okay, tangent. Generally I can see where there may be a benefit there, but those are all the things to weigh out because bottom line, what if they’re already a current patient? And this has happened to me. I had an office that they joined. And they were getting a hundred plus per visit.

When they joined, they got dropped to 60 and I thought, didn’t you find that out before joining? So before you join, really ask the hard question, What does it pay? Realize, because of the no surprise act, the insurance company have to be forthcoming with what they’re going to allow. So be careful before you join, really start to weigh out all these factors, and you may look at some other things as well.

Sometimes these plans, as America Specialty Health, may request that you send pretreatment author. After a certain number of visits. Now, I won’t say those are very hard, but that’s a lot of extra work or at least extra work that you have to do after five visits. Is that worth it when you consider the time that it takes to do it Now, what if it even only takes 15, 20 minutes?

That’s still time. So again, we have to weigh all those factors in. Now, if it has a lot of things that you’re required to do, maybe. If it’s relatively simple, and again, you have to learn to make it work and understand what they’re looking for. But you can see here this lens toward be a little bit more scrupulous.

Don’t be afraid to be a little bit more focused on is there enough value here? Now, the good news is, let’s say you join something and it turns out to be horrible, and you’re like, Oh my God. You can always drop out, but bear in mind, dropping out is not immediate and be also conscientious that when you join something, always ask.

What other plans will this join me to? By example? If you join a group like multi plan, it’s not just one. It often attaches itself to several things and be conscious that you can sometimes opt out of these types of plan. You can say, Okay, I wanna belong to this one, but not that. So by example, with some as H policies, you can choose to opt into Blue Cross, but not Blue Shield or Cigna and not Aetna.

So before, always look at what do I really want to join? What’s good for me or what’s not so good and see about opting out. At the end of the day, it’s all about the value, The business value, I would say. Think of what your cash rate. Cash rate is meant to be simpler, less because there’s less work. I’m not saying insurance coding and billing is hard, but there’s more time.

So often for cash patients, we’ll offer like 10% off because know, we don’t have all the other background paperwork. Okay? So think of that rate. In my opinion, I need at least that to be darn close to what my cash rate is. Now, obviously I don’t think anyone has a cash rate as little as. So I’m looking at 60 or 70.

So a lot of these plans I look at and go, I’m not so sure unless I can really make it up in the volume. But I wanna look at does it match that, or at least this, Have you ever thought of, what does it cost to treat a patient in your office? Really, know, what’s your bottom line? What does it take for me to just keep my office open?

Now how do we do that? What I’d like you to do is to take your office over. What does it cost for your office? And that includes your rent, your lease, cost of needles, table paper, everything to rent in your office. You know what I’d actually include with that? I’d include student loans. I really think that’s part of your office cost.

But anyway, take your overhead, then divide that by the average number of patients per month. Notice I didn’t say, or excuse me, patient visits per month. Not patients, but patient visits. So by example, let’s say your overhead cost is $4,000. That’s what it costs to run the office, and 25 visits per week or a hundred per month.

That means in order for you just to break even and pay for the office, you have to get at least $40 per patient. So when you’re looking at a plan like an ASF that’s paying 40, you’re making nothing. So unless you can increase the volume, this really doesn’t help. So be careful before you decide to choose.

You cannot do this at a loss. It’s gotta be with some level of profit. Now, maybe you can have an office cost that’s only $15 or $20 a patient. So some things to consider, but I really want you to look at the business side of it, and this is the part maybe we don’t like doing. You want the school to be an acupuncturist.

You are good at what you do. You help people. The part we don’t like is, What do you mean I gotta deal with the business end? And that is an important part because unfortunately a lot of acupunc. Within three to five years of graduation, don’t practice because they simply couldn’t deal with the business side of it.

And I want to help you with that to say, could this make a difference? Now what if you join this plan and though it doesn’t pay very much and that doesn’t meet the overhead expense, but what if you have an office, you’re not very busy, and you have openings for another 20 visits per week or more.

I would rather fill them with these than not have them at. And then maybe you can build the practice from there on other referrals and get them sold on maybe maintenance care. So there’s some things to consider here, but I want to be careful that if it’s gonna take away an existing patient and all of a sudden now you’re replacing a hundred dollars patient with a $40 patient, not a good idea.

Realize that under ash, depending on the plan you join, whether it’s Cigna or others, the reimbursement can be as little as 40 to about $90, which means in this aspect, you could be making $0. Actual profit to maybe 45 per patient. Now that’s not awful, to get 45. In fact, I think we can make overhead a little bit lower.

So let’s take a look at like Ash with Cigna. And I’m gonna say this varies from state to state. I’m giving you just one state here, and you’ll see here they allow 51 for the first set, 38 for the second, but it’s just a maximum of two. Means you’re gonna get $89, you’re not gonna build multiple sets or therapies.

They’ll either pay two codes and the max is 89 per day. Now is that. No, I think that’s reasonable. I think that fits a lot of people’s cashes too. Two sets, meaning you can do it 30 minutes, they do pay separately for exams. But let’s be honest, notice the exam price are only 20 to $40. So when you’re getting managed care, you gotta know that I’m gonna get probably less than a hundred dollars per visit.

Can I make that work? Does the volume hit it? And remember, this is an ash tier. When you join Ash, and I’m not saying this is negative for ash, I just wish they paid more. Most acupuncturists when you join is gonna be put at a tier three, which means when you’re a tier three, after five visits, you have to send more information about the need for care from the patient.

Now, as you’re in the plan for a length of time, you may reach a tier six where you don’t have to do that because they know that you’re trustworthy. You’re not over utilizing. But you can see here, there’s extra work. Now, again, I’m not against it, and there’s ways to work with that. That’s one of the things I do with our network services to help you with that.

But I want you to also look at this overall and know yourself. If you know that you spend more time, if you know that you do not like to do extra reports, this may not be for you. You’ve really gotta make the hard choice of is there enough value for me? I’m not against joining, but take a look at the plans and what the incentives.

How does it increase the volume of patients? Does it bring in 10 general patients? So let me give you a kind of a quick primer about what must or should you join. I’ll never say must, but these are just my opinion. I will certainly say if you’re joining the va, that’s a win-win, meaning there’s no negative to that, in my opinion.

If you join the va, whether you’re on, Texas or west of Texas or East with Optum, Tri West, or Optum, when you join, there’s no cost to join. And the only access is to VA patients. Now, if you get a VA patient, it’s great that VA patient’s probably gonna equal 1500 to $2,000 of reimbursement for the amount of services they offer.

So I’d say, Okay, there’s a value there. There’s no downside, because if you join the worst thing that happens, you don’t get a patient. If I get just one or two a month, that certainly could be worth it. So I think for me, there’s no issue there. I think HMO plans like Medicare Part C. Now notice I’m saying Medicare Part C, I’m not talking regular Medicare.

I’m talking the Part C policies with the additional acupuncture benefit, those I have no problem joining because again, this is exclusive. If you’re in, you can see the patient and these can actually decently reimburse. They give access not only to acupuncture, but to exams and therapies as well. So those I have no problem.

Again, no cost to joining. What about optional plans? You know what? If I wanna join an a sh or Primera or Blue Cross Blue Shield look to see what does it do, what else does it join you to? I would start with, is it exclusive? Is my number one issue. Cause I think if I wanna bring people in, think of how many times you’ve had a patient come in and has this ever happened to you?

Have you ever had a patient that you gave a hardship? that you hardly charge ’em anything, but you wanna be helpful. That’s what you do. And in turn, that patient wound up referring you many patients. So realize there’s more benefits that could be there, but you wanna start to weigh that out. Is there enough value outside of this?

I’d really have to work with the individually to say, Okay, let’s talk about what area you in, What part of the country, what county, what city? Who is insured there? What type of plans are you seeing? Is there enough a benefit to do it? Does it pay enough? Now, as you can tell, this is complicated. The good news is you’re never stuck, but you do wanna make some choices and decide whether or not it works for you as a business provider.

At the end of the day, you are providing a service that has a value, and that value has to be enough to pay for you and your office, but just your home cost as well. So it’s something to consider. I would say certainly take some time to look through it. Don’t be afraid to be a little scrutinizing, and if you jump in one.

Don’t like it. You can always jump out. Keep in mind though, one thing, you can join one plan and not necessarily have to join the other. So when you join like a sh, make sure you know that. Can I opt into one plan? Maybe I belong for Cigna, but not for Ner or some of the others. So keep in mind to always look at all the aspects of whether or not, what do I have to be in?

What am I automatic or what are optional? Cause I would certainly not wanna be part of personal injury or some of these other things that may be involved with them. And that’s what we do at the American Acupuncture Council Network. For some of you, You may have already been familiar with this, but it’s a chance for me to be part of your staff.

Give me a call, send me an email, do a Zoom meeting with me, and we help your office. Take a look here. Just go to our website or do this QR code. We’re here to help. We always want to have you to have the best possible practice you can. That’s really our goal. So we’re always here to serve American Acupuncture Council Network.

Here’s our phone number. Go to our website. I will say to all of you, best wishes, and don’t be afraid. Make that choice. Decide what works for your business. We’re here to support you. Until next time, everyone take care.