Blog, Chirosecure Live Event October 9, 2022

The Pros and Cons of Joining an Insurance Network

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Hey, friends and colleagues, Sam Collins, you’re coding and billing expert for chiropractic, ChiroSecure, and of course the HJ Ross Company. Here’s something that comes up quite a bit in doing seminars and of course doing our network service where we help you one on one. I get lots of questions about, Hey, Sam, should I join this plan?

Is it worth it? What’s the good one? What’s the bad one? And of course, there’s a lot to decide there. So manage care, Is it worth it to join or not to join? Is the question. Let’s cover that today. Let’s go to the slides. All right, so managed care. What does that really mean? It means we’ve joined something.

In other words, they manage us. The idea is, hey, maybe by joining we’re gonna get access to patients we might not otherwise have. So when you hear the term managed care, you’ll often hear terms like preferred provider. Or a member provider. And the bottom line is this gives an insurance planner, gives you access to an insurance plan that where you have to be a member, but it gains access to the patient and to payments.

I would say certainly plans that are exclusive, meaning that you have no payment if you don’t join, are gonna be the more likely ones to join. But even then you have to decide whether or not is there enough value. Because these plans, of course, offer a trade off to the provider and this is where we have to make a decision.

Is that trade off worth it? In some ways, this sounds awful, but I think that some of these managed care plans are the 99 cents store of chiropractic. I’m aware of some as h plans that pay as little as $26 a visit. How do we make that work? Is that really worth it? Is that trade off there?

So the whole trade off really is more access. If the plan has no benefits for non-members, then I’m gonna say, Hey, that’s great. It gives us access. Otherwise, without it, like by example, Medicare, if a chiropractor decides not to join Medicare, Actually, you can’t even see the Medicare patient for cash.

You have to be part of Medicare in order to bill, in order to get paid by the patient, but you still have to register as non-par, still submit the claim. But in doing this, you’re gonna get access. But what are we gonna get in turn reduced or limited reimbursement. Let’s face it, none of these plans are gonna pay your usual and customary.

Now, sometimes it can, some can be better than others, but this is where we have to make a decision whether or not. There enough value, and in my opinion, it comes down to the 99 cent store model. Can the volume make up the difference or does it fill in space by example? As you’re, many of you’re aware, my father was a chiropractor in his office.

One of the things in the nineties when a SH first started, They actually paid better, but when they first started, we decided to join because it was gonna give us access to people who had Kaiser, which is a very big HMO on the West Coast, and also the health net. Very big HMOs that otherwise would have no benefits.

So to us, It wasn’t so much the volume, it gave us access to people who otherwise would not have had care with us, or at least not insurance benefits. And one of the things we learned is many people, if their insurance doesn’t cover, doesn’t go in. So we gotta balance that. Obviously we still wanna do a large amount of cash, but at the same token, there’s a balance of those that wanna do it.

What we wound up doing though, to give you some personal experience with that, when we joined, we initially joined kind of everything. And we learned pretty quickly, we didn’t like the everything, cuz sometimes it took away patients we already had. So we decided just to opt into the HMO part of it. So we got the patients that otherwise had no benefits cuz there were some that did.

So when you’re making a decision about joining, what you really need to do is use some simple steps to do that. Now this is something that I go in great detail with our network members. Why give you a little bit of a primer to it Here? You take a piece of paper, literally draw a line down the middle.

One side says yes, One side says no, and we decide how many yeses or no’s and whether or not it’s worth it. So the first thing I’m gonna look at, is it exclusive? That’s really to me, the most important. Why join something the patient can go anyway? What’s the incentive? So if the patient can already come in and you join, it literally means you’re gonna get less money.

Unless you can say, Oh no. By joining I got a lot more people. Let me give an example. United Health. United Healthcare you can join and it’s gonna be through Optum Health and you’ll get a fairly limited $60 per visit reimbursement or a lesser reimbursement if you’re out of network, you can actually get paid more and it’s interest.

And we do a seminar. I didn’t want just past weekend and I asked some of the providers, Okay, who belongs to United? A lot of hands went up, Okay, where do you getting paid per visit? Okay, great. Now why’d you join? Getting that. Then I said, Okay, now after we did that, some of ’em joined, Will it gained access?

I said, How many of you don’t belong to United? He. Few hands went up. I said, Great. Do you bill United Healthcare? Oh yeah. What do you get paid per visit? Often double. So before you join something, make sure that the plan’s already not gonna pay you. Cuz if you join, it’s gonna pay less. So to me the number one rules gotta be, it has to be exclusive or it has to be so attractive that otherwise the patient wouldn’t come by example.

There are some United healthcare policies that if you go to an out, if a patient goes to an out of network, The deductible could jump up to a couple thousand dollars. Maybe in that, in a sense it could be worth it, but you really gotta weigh out whether or not does it give access that I otherwise wouldn’t have?

Because if it’s non exclusive and it reimburses non-member providers, what’s the point? Why am I doing this? And I see this time and time again. I’ve seen it with Cigna, I’ve seen it with some Aetna plans. Now the next thing to look at though, it’s not just as of exclusive, does it pay reason? Does the pay make sense?

Realize because of the no surprises act, they have to be very forthright. What do they actually wanna reimburse? And I’ve had some plans recently that are reimbursing the 60 to 80 range and go, Eh, that maybe. Okay, but what about a plan that does 26? I’m gonna say not reasonable. That’s not enough to maybe meet your overhead.

We’ll talk more about that. But you gotta really look at, does that pay really match the level of service I’m providing? Cuz bottom line, if it pays too, I’m gonna cancel out. What if a policy is exclusive, but it pays very little. That cancels out. Something else has to make the difference. And to me, that difference has to be volume.

Can it bring me a lot of new patients? If it can’t, what’s the point? But if it can, what if all of a sudden you had extra patients? And I’ll give an example. We did belong, as I mentioned, to a. Under the Kaiser and Health net. And the reason why is it brought us a lot of patients that otherwise wouldn’t come in.

We were in an area where there was a large Kaiser facility and a particular Arco Richfield, which has now changed to just Arco, I think for our refinery. And most of the employees there had the Kaiser plan. So what it did was give us access. What we learned early on though, those patients came in, they got a really good adjust.

If they wanted some extra bills and whistles, they had to pay for it. But we got them in and we made about three to 4,000 a month. And so it was worth it cuz they were patients we otherwise wouldn’t have gotten. So maybe new patients could be, but again, always what if they’re already current patients?

Think of it. I had someone the other day said, Hey Sam, I’m gonna join this plan cause I’ve had two patients that want me to join. And I thought, they’re already patients, so what’s going to make it different if you join? And so we looked into it if they joined, and I’m kidding you. The amount they would get paid is about half of what they’re getting paid now.

So I thought, what sense does that make? Unless somehow the patient’s gonna leave you, that makes no sense at all. So be very careful and they make us this appear very enticing and realize when you join something. Always know what else did I join? Some of these plans when you join will hook you into a personal injury, maybe hook you into work comp, and frankly, they never send you those patients.

They just take a piece of your money. So always look to see, can I opt out? What about this? Some of these plans require authorization, meaning after a set number of visits, you have to write a report. Now, I’m not gonna say these. Are hard, but they’re consuming. They take time. 15, 20 minutes of extra time.

You get paid nothing for it and you’re fighting for every visit. Sometimes it’s as little as five visits. So certainly, I’m not saying that’s a bad thing per se, but you have to know that going in cuz nothing frustrates me more when someone says, Oh my God, I joined the plan and they require preauthorization.

And I’m like didn’t you know that before you join? Always get all the information. I want something that, if it’s a tedious reporting thing, maybe I don’t wanna be part. Some plants force you, if you’re in Washington by example, the company Perera after six visits, you have to get authorization.

If you’re doing physical therapy, it doesn’t matter who. So that’s just a necessary evil. But at the same token, none for chiropractic. Meaning the adjustment part. So you really gotta start to weigh what are the pluses and minuses. And frankly, what I’ll tell you is look at it from a business standpoint.

You are running a business. Put this onto Shark Tank. Does it make work? Because I’ll start with what is your cash? . Does it make fiscal sense? I think most people have a cash rate that’s relatively cheap and simple. And if these plans don’t at least hit that, is it worth it? Now, maybe again, volume always helps, but again, it’s something we have to weigh in, whether or not there’s a value.

And you can see, I see, to be mostly talking negative, but I’d rather take away the kind of hyperbole of this. Oh, I’ve gotta join everything. Remember, once you’re licensed, you don’t have to join a thing. You can start. Most plans don’t require you being network. Some may, but look to see, does it make fiscal sense?

What I’d like you to think of though, if you’ve never done this, what does it cost to treat a patient in your office? This is one of the things I do with every new network member of the platinum side is let’s look at your overhead and cost, and let’s start really looking at does what we’re doing make sense?

If you have an item, you’re putting it up for sale and it costs you $5 to make. and you’re only getting $3. That makes no sense because it’s costing you more to make it than you’ll receive. So I want you to take your overhead, all your related costs to run your office, and then the average patient visits you have per month, approximately.

Now ChiroSecure can be pretty busy. I’m gonna say most of you’re gonna probably do about a hundred per week, or 400 and so per month. So I’ve done these numbers just to illustrate it. Let’s say your overhead rent. Your staff, any of the other costs, phone bill and all that is 6,500.

You then see about 425 patient visits per month, meaning a little over, know, a hundred per week, give or take. That’s a busy office, but not crazy. I know some of you’re gonna say, Sam, I see a hundred a day. I get it. But if you’re doing that volume, that means you need $15 per patient to meet the overhead.

So that means if you are making asch money, you’re getting $11. Ooh, that’s rough. Now realize, because you’re maybe seeing more patients, maybe the number gets smaller, cuz you go from 1 25 a week to one 50. But still, you can see that profit margin is small. Now what about a plan like Optum Health?

Optum Health is a plan. You can join but don’t have to. But if you join, you’re gonna get a $60 per diem payment. Which means about a $49 profit. I could live with that a little bit better, assuming I get five or six of those a day and I’m efficient with it. But I would also be careful, what if all of a sudden you join these plans and you go, Wow, I’m starting to get a lot of referrals, but wait a minute, I have say 20 to 30 visits you have per day.

What if you’re inundated with 20 to 30 of these patients and there’s no room for the patients that have much better policies or paying cash for that matter? So you gotta start to weigh all those things in. Here’s the tough. Did anyone ever tell you when you’re a chiropractic college, you’re gonna be a ceo?

They may not have, but you are because you’re running this business. So we have to look at that business value or a business value, and does the volume make up the difference? And it can. Like I mentioned in the practice with my dad, that’s what worked out for us. I didn’t like doing the reports.

My dad frankly didn’t care. He goes, They’re no big deal. Why he didn’t care cuz he made me do them. So from that standpoint, what I did learn though, is certain things they were looking for and understanding that protocol, and that’s a whole nother program we can do to make sure you’re getting the visits you need.

Just remember, with these plans, they’re not giving you 20, 30 visits. Let’s be honest. Most of your patients within a month of care, how many of your patients really are doing pretty good? Now, I’m not talking the more severe stuff, but you know the run the mill back pain? Yeah, within a month. Easy. In fact, I think your patient would stop coming if they don’t get even better within a week or two.

So let’s be careful of always thinking we need a lot of visits. That’s the maintenance side, preventative side, and I agree with that, but that’s probably more cash. So when you join these figure out what do they allow? So here’s the plan for American Specialty Health. A sh. Now, I don’t think this is a bad plan at all.

I don’t think they’re preauthorization. Is that complicated once you understand it, the only bone I have to pick with. Is there too little per visit and they’ve not increased it. But you’ll see here, depending on your tier, and most providers are gonna start at tier three, you’re gonna get five visits. So it means after five you have to then request more.

Now the. Maybe you do less than five, you’re okay. But as soon as you go more than five, there’s an extra report that takes time and it’s work. So that becomes, oh, wait a minute. Now if you’re a good guy or good girl, if you will, and you don’t over-utilize, they’ll move your tier up to eventually you get to a tier six where you won’t have to request.

But that means you’re also a provider they can trust. If you max out everyone’s policy, that’s gonna be problematic. So if everyone who has 40 visits, you automatically give them. That’s a problem that it’s not to say they don’t get 40, but they’re not entitled to 40. They’re entitled to 40 if they have a condition.

So we gotta really balance out the maintenance side of it. What about something like United Healthcare? It pays a little better, but it’s a flat rate. It’s a all encompassing scope of practice payment. It includes e m codes, x-rays, and treatments. So if you have a patient on a first visit, you examine, you do two sets of x-rays and you adjust with the therapy you’re getting.

The next time they come in, if you just adjust, they’re gonna get 60. Now the idea is they’re gonna give you this amount. They, I think it’s a little bit fair cause it’s close to say 55 to 60. But at the same token, what about the days you’re doing x-rays and exams? Ooh, Now what they’ve done, at least this is what they’re saying, they’ve done the math that this kind of equals out over a course of care.

The good news is they don’t require preauthorization. So that doesn’t mean you have to do any extra reports, but here’s something to. Does this work within your model of cost? Does that really meet? Can you be efficient? Sometimes you have to be careful. I think we often too much in our profession get married to the four s, meaning the modalities, the passive care.

Do all patients really need a half hour massage? Is that really what’s gonna make them better? How about relying on a good adjustment? I have a friend that practices in an area where it’s inundated with. And he goes, Sam, I had to make it work because I live here now. So what he’s done is made it a very efficient practice.

People come in, they pretty much get adjusted and they leave. He has to do a very high volume. He does do some personal injuries, some other things, but it’s a good bulk of his practice. At the same token, when someone needs something else, remember you can always tell them, Hey. , this plan doesn’t cover a therapy.

So by example, as H doesn’t cover massage, so that’s something you could charge extra, but not when it comes to Optum. Optum says, Nope, it’s all inclusive. So you really wanna know what the plans require before jumping in, because nothing is frustrating for me more than having you contact me and then we work backwards on this.

So before you jump off that plank, get some good inform. . Now, one of the things I’ll give you here is at least a little primer on what you must quote unquote, or should maybe join. Now, I will say, again, this my opinion, I would say a chiropractor should join Medicare. Why? Because if you don’t, you can’t see them.

Literally, if you don’t join Medicare when someone’s 65, you have to turn them. Because for Medicare, you must be enrolled in Medicare, but you can still do it as cash if you will register as non-par. The patient comes in, pays you the rate, which is called the limiting charge by Medicare, but you have to submit the claim to Medicare on their behalf and they get the check, but you still have to submit the claim.

Now, if you don’t do that, you can’t see them and don’t get caught trying to have the patient do a super bill. Medicare will not accept that from the patient. I say do the simple. Medicare patients often with the types of conditions they have based on age degeneration. I would say it’s not unusual to get 20 to 30 visits a year on a Medicare patient.

Now, the average Medicare reimbursement is about $40 for manipulation. I’m not including all the other stuff. So let’s say you’re doing about 20 visits on your average Medicare patient, that means you’re getting about $800 of reimbursement, just manipulation, not include anything else. So if you’re getting 20 visits, what if you have a thousand Medicare patient?

That’s $800,000. Now, that’s a lot of visits, don’t get me wrong, but I wanted everyone to see, I don’t know why we shy away from this. We fight to join some of these other plans, yet a Medicare actually pays better than a sh doesn’t have all the other stuff. The key is just understanding how Medicare does it properly.

One of the things, if you’ve never attended a seminar with me, learn how to make Medicare simple. We have a simple four step process. Once you learn it, it’s not hard. You know what makes most people not like? They never learned it properly. So they’re frustrated, and of course, all they hear is hyperbole.

Something else I probably would suggest joining would be the va. Here’s my reasoning, just like Medicare, you can’t see the patient without being part of it. Now remember, a VA patient could see you and pay cash. Yes. But for someone that wants to use their VA benefits, you’ve gotta join either Tri West or Optum.

Remember, Texas and west of Texas is Tri West. Everything else is Optum. , would I join that? Sure. Cuz the only downside in my opinion, if you join, you don’t get a patient. But if you market it you probably can. What about Blue Cross Blue Shield? Now this varies from state to state a little bit, but one thing I’ll tell you about Blue Cross Blue Shield, if you don’t join, Blue Cross and Blue Shield have a special rule where they don’t have to send payments to non-providers.

So if you’re out of network with Blue Cross Blue Shield, don’t be surprised when you go, How come the patient got the check and I signed? Because they have a special rule for it. Now, this may not be enough for me to join, but it may be something to consider. And I often find they don’t really pay much differently when you’re in or out of network on most of those plans.

Now, obviously you can charge a little bit more, meaning the patient pays outta pocket. And what about other plans? Now when you start talking Aetnas and Cignas, my general is probably not, but what you wanna look at is it exclusive and you’re gonna get a lot of solicitation from different people.

Oh, join us, we’ll send you people. Be very careful before you do that, cuz what I often find is you join them and they sell your name to someone. And by selling your name, you’ve now become in network. And when you were getting a hundred before you could all of a sudden be getting. Only because you joined.

So before you jump off, make sure what does it attach me to? Don’t get caught with what we call a silent ppo. You joined one thing and didn’t realize it entrusted you to five others. But something else to consider is what about Writeoffs? If you have a tendency where you’re writing things off, you might as well join and be in network and do it legally.

Cuz remember, you can’t do a legal write off of your price unless you’re in network. If you charge someone $200, and their plan pays one 50. They owe you. Bill another patient, the same 200. If their plan pays 50, they owe you one 50 when you’re out of network. So here’s an example of a claim, and you’ll notice here I put the red arrow.

It shows it’s out of network. Okay? You’ll notice that they build them out pretty expensive, $349. The plan doesn’t allow 200 or allows 205, which is pretty good. I’ll take that 205. Being that you’re out of network though, notice you have to collect $143 from the patient because they’re gonna pay 2 0 5, but you’re still gonna collect 3 49.

Now, can you legally write off that 1 43? No. If you’re billing 3 49, you have to collect 3 49. You cannot just accept insurance is full. Cuz what if another patient comes in, they have a similar plan and it pays the thing in full and you go, Oh, that’s great, but yet this person doesn’t either. So if this office has a tendency to write this off, I would be telling you probably want to join because if you get caught with this, right?

If it’s a major problem and I see what they do with this, when insurance find that out, they just turn it into the board. So be careful, which means another risk management tip. How many of you have checked your malpractice policy to see whether or not that’s covered? If you have ChiroSecure secure, you’re covered.

They’ll help you with the audit and defend you. They’ll hire the legal help, the expert help to do it. But this could be a reason to join if you find that ham and it’s off. Now, I take this patient in a heartbeat. By the way, this is a blue. Ppo. Now notice ppo, PPO means preferred provider, which means a patient doesn’t have to go into network, but when they go on a network, they have to pay 143 bucks at least to you.

So something to consider. So here’s what you have to think of. You’re running a business and every business, you have to adapt. Think of Sears. Sears didn’t adapt, Did it? Wasn’t Sears, Amazon. If you really think of it, Sears had all the infrastructure. Why didn’t they put it online? They didn’t went out of business.

But there’s something else interesting. You ever notice and you go into a target store when you first walk in, there’s a few aisles of 99 cents store items and it, I think Target is brilliant in doing that because they know people like that. So it’s a way of satisfying that, which means, Look at other chiropractic models.

What about the joint? And I don’t want everything to be dependent upon insurance. Sometimes you might say, You know what? I don’t belong to any groups, but what we do offer are packages. That’s a whole nother program. But that might be another way of you starting to get patients to come in and understand the value and a different way to pay.

Always make sure what’s the big barrier for most people coming in cost. And I’m not saying we make it free, but how do we mitigate it to make sure they can afford it? Think of it when someone is selling a. Do you ever notice? They don’t tell you the full price. They tell you the monthly price, so it’s one of the things to consider.

What I’m gonna say to you is, make a good choice for you, but vet it a bit. I’m gonna suggest let me be part of that process. Our network service allows me to be your in-house expert. Once you join, you can call me, email me, You name it. We do zooms and it includes two CE seminars here. So you can look at this QR code, take a look, see what we offer.

I think we’re gonna help your office make a lot more money, but HJ Ross is always gonna be a resource for you. Here’s our phone number. Here is our website. We’re always gonna be there, but remember ChiroSecure. HJ Ross. We’re here for you, so please go out. Be successful cuz I’m counting on you because I want chiropractic to be that number one source of healthcare.

For most people, it should be that first place they go. Until next time, everyone take care.