Many acupuncture providers have trouble deciding whether or not to join insurance networks – and what’s right for one practice may not be right for another. There are both positive and negative aspects of joining an acupuncture insurance billing network, depending on your geographic location and your practice’s needs, but understanding the pros and cons requires knowing a little more about HMOs and PPOs, in general.
Broadly, there are two major benefit types: HMO and PPO. In an HMO plan, a patient is typically required to select only doctors and providers from their HMO’s network. In most instances, the patient is required to obtain referrals from their primary care provider (PCP) to receive acupuncture treatments.
With PPO plans, a patient has the option to select any providers they like – no referrals needed. They can select providers that are in-network with their insurance, which is preferable since their costs will be lower, or go to doctors out-of network. Although patients with PPO-level benefits have more freedom in choosing their providers, they also tend to have higher deductibles and coinsurance costs.
Pros to Joining a Network: Larger Pool of Patients & More Referral Opportunities
Joining a particular network allows you to treat both HMO and PPO patients in that insurance network. (If you stay out of an insurance’s network, you are limited to seeing PPO patients who choose to use their out-of-network benefits at higher cost.)
Being in-network also enables you to accept more patients who have HMO benefits only. After joining a network, your name and practice information will be posted to the insurance carrier’s website and database, potentially garnering you a larger clientele and more referrals from patients’ PCPs.
Cons to Joining a Network: Lower Payments, More Limitations
On the other hand, by signing up and agreeing to an insurer’s contract providers in-network typically get paid at a lower fee schedule than providers who are not contracted. In-network providers also usually cannot bill patients for the remaining portion of a balance for a service that the insurance does not cover. (For instance, if you sent a claim for $120.00 and the insurance paid only $40.00, you would not be allowed to bill the patient for the outstanding $80.00.) If you’re out-of-network, you usually have the flexibility and freedom to bill the patient for the difference to make up for any low insurance payments.
Another negative aspect of being contracted into a network is that you could be limited to billing only acupuncture codes – whereas as an out-of-network provider, you can utilize numerous other modality codes. (For example, United Healthcare covers for Gua Sha for non-participating providers, but not for in-network acupuncturists.)
Additionally, being a contracted in-network provider often shortens your claim filing time. Usually, providers have a one-year window to submit their claims; a January 1 claim can be processed so long as it’s received by December 31. If you are contracted, however, your timely filing period can be cut down to 3-6 months. That may sound like a sufficient amount of time, but claims can easily fall through the cracks – on your side or that of the insurance company.
Lastly, getting contracted with an insurer is tedious work. You’ll need to fill out a thick packet of questionnaires about your experience, practice, and degree and then give the insurer three months to review and approve your application. After that, you’ll need to revisit your paperwork often and meet the insurer’s particular standards to maintain your in-network status.
So What’s Right for You? That Depends
Conduct some analysis on your business to determine the cost/benefit. Only you can know whether or not your practice should join a network. Weigh the benefits of increased visibility against the reimbursement ramifications and if you are still confused feel free to contact us on this or any other issue related to acupuncture billing services.
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