Can I Really Be a Cash Practice?
FEATURE
Kathy Mills Chang
MCS-P, CCPC, CCCA and Yvette Noel, CPCO
Do the increasing demands from payers seem to stifle your practice? Are you overloaded with forms to complete after five, eight, or 10 visits? Does it feel like you pour your heart and soul into jumping through their hoops only to have a behind-the-scenes desk jockey who has never seen your patient decide about the care you have prescribed? Sound familiar? Join the club with many other providers in our profession.
The chorus of doctors we hear from every day pretty much all sound the same. “I just want to be done with insurance.” “Why do they get to tell me how to run my practice?” “It’s just not worth it anymore.” As demands placed on practices grow, and changes to our industry evolve, transitioning to a cash practice seems more appetizing every day. However, consider these questions when contemplating an all-cash model:
• Will I lose a large base of patients if I stop participat-
ing with their insurance?
• What plan should be in place to keep my revenue flowing during the transition?
• Will I work with insurance in an out-of-network capacity?
• How can I attract new patients without accepting their insurance?
• Will I still bill on behalf of patients or just hand out superbills?
• Will I still see Medicare patients? Perhaps as nonparticipating?
Are You Already a Cash Practice and Don’t Know It?
You should be very familiar with all of the payer policies relative to the care that you render in your office. For instance, Aetna has a very long list of excluded techniques when reporting chiropractic manipulative treatment (CMT) services. It can be both shocking and frightening the first time you see their payer policies only to find that your primary technique isn’t even covered. A simple web search often yields the medical review policy for any payer in question. As a contracted provider, your agreement is with them, and they set the rules of participation. After reading the payer’s list of exclusions and limitations, many doctors are left scratching their heads trying to figure out what is covered, given that every technique they perform is on the exclusions list. You may not see the big deal here, thinking back to how they have always paid when you submitted the claim. Keep in mind that the CMS 1500 form is a federal form and reading the red ink on the back should enlighten you as to how to properly utilize the form, as well as understand the repercussions for not doing so. Therefore, it is your responsibility to know not only the proper usage of the CPT code, but also the payer’s rule regarding the service and code. This is where you may discover that you should already be on the road to becoming a cash practice. In these circumstances, if the patient elects to have the service, they agree to pay cash.
"For instance, Aetna has a very long list of excluded techniques when reporting chiropractic manipulative treatment (CMT) services."
Can You Afford to Stay with Insurance?
There are costs to the practice when participating with payers. Hopefully, the costs outweigh the benefits. Utilizing a cost-per-visit analysis will help you evaluate exactly what it costs you to operate your business. Dividing the total overhead in a year by the number of visits in the same period yields the approximate cost to the practice per patient visit. Once you have found this magic number, work through a comparison of your allowable reimbursement from the payer to evaluate profit per visit. Now, think about your typical day. Are you primarily just performing CMT services? If so, let’s see just how feasible it is for you to continue at this same reimbursement rate from the payer and stay profitable in business. Consider, as well, all of the extra staffing costs. With the many requirements and nuances to be managed in an insurance practice, it can be a full-time job for an employee just to do insurance verifications, billing, follow-ups, appeals, and so forth. The time adds up quickly.
Making the Move
Once the cost-per-visit average is calculated, fees are compared to allowances, and profit is estimated, you will be in a better position to make a move. Think about who has the lower reimbursement among your carriers and which payer covers the fewest of your patients. Start by calling the payer that you wish to terminate your contract with and ask them the proper steps and requirements of going out-of-network. They likely will have a system that you must abide by while your contract is still active. This will include alerting your existing patient base covered under their plan and notifying any potential new patients that you are going out-of-network.
It is recommended when changing your network status with a payer that you determine if they have a “deeming” policy. This is more common with Medicare Advantage plans, but it is something that you should verily. Deeming is a process by which a payer will place you in-network and subject you to their fees and regulations when you present a claim for payment.
But It’s Too Expensive for the Patient
While some patients have excellent coverage, more have very high deductible plans and restrictive coverage for services. Many patients are already electing to become cash patients in your office by foregoing their insurance. It’s usually less expensive than utilizing the insurance at the payer’s fee schedule.
Don’t Think It Is Over
To be 100% all-cash also means not treating any Medicare patients if you are not enrolled. Chiropractors are not permitted to enter into a private contract with a patient or elect to opt out. Here’s the catch: if you choose to stay enrolled with Medicare so you can continue to see this faithful batch of good patients, you also become subjected to rules that spill over into the rest of your practice. So, if your choice to go all-cash makes you think you are home free—you can think for yourself, do for yourself, document (or not), go back to your travel card—wait, not so fast. Remember that state laws also govern your practice, and you need to be familiar with their requirements as well.
More chiropractors are choosing to forego insurance. It’s not for everyone, so whatever you do, don’t dive in without considering all of these points. Either way, make a business decision that is best for you, your team, and your patients.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P), certified chiropractic professional coder (CCPC), and certified clinical chiropractic assistant (CCCA). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 30 at KMC University and is known as one of our profession ⅛ foremost experts on Medicare, documentation, and CA development.
Yvette Noel is a senior membership advisor and conference speaker with KMC University. She is a certified professional compliance officer (CPCO). She has served the chiropractic community for 13 years and has worked in the medical field since 1988. Through this experience, she has continued to develop her skills in medical coding and billing. Before coming to KMC University, she managed a very successful chiropractic and occupational health business. She remains very passionate about KMC University and takes much pleasure in helping members with their documentation, reimbursement, and compliance needs.
Kathy or any of her team members can be reached at 855-832-6562 or [email protected].
