Weighing the pros and cons of joining payer panels
Will you join one or more payer panels, or will you only accept self-pay clients? It’s the question every therapist must answer when establishing a private practice, and it’s probably one of the most important decisions any provider will make, says Dylan O’Hare, SmartBilling Pro Manager at SimplePractice. Dylan has more than 10 years of experience as a medical biller specializing in mental health. There’s no right or wrong answer, and as a small business owner, you need to make the decision based on what will help you generate—and sustain—the most revenue, he adds.
Pros and cons of accepting insurance
As with any tough decision, there are pros and cons to both sides. First, let’s look at the pros and cons of joining a payer panel. One of the biggest benefits of becoming paneled is that it opens you up to a wider pool of potential clients, many of whom benefit from low-cost healthcare coverage under the Affordable Care Act, says O’Hare. “Even those who can afford self-pay would rather use their insurance because they’re already paying for that,” he says.
Other benefits include free visibility on the payer’s website and a smooth cashflow, says O’Hare. Payers tend to have predictable turnaround times—often within 30 days—for paying claims, making it easier to plan ahead and budget, he adds.
On the flip side, joining a payer panel means you won’t get paid unless you submit claims with accurate medical codes. This requires your most limited commodity—time, says O’Hare. Time spent billing payers to recoup revenue is time you could instead spend seeing clients to generate revenue. Robust billing software helps maximize efficiency, but you’ll still need to address denials and respond to payer audits. “You’ll likely have to see fewer clients every week if you want to stay on top of this,” he adds.
If the idea of adding non-billable hours to your workweek isn’t ideal, you could consider hiring a biller or administrative assistant to join your practice, says O’Hare. This can be costly, though, and you’ve got to find someone you trust because you’re essentially putting your financial success in this individual’s hands, he adds. Another option is to outsource the billing to avoid overhead costs.
Another disadvantage is that it often takes payers several months to decide whether they’ll accept you onto their panel. If an area is inundated with therapists, payers tend to be picky and choose only the most experienced candidates. Payers also close their panels to new providers periodically. “You could find yourself in a situation where you fill out all of the paperwork and wait a couple of weeks only to find out that the panel has closed or was already closed,” says O’Hare. Inquiring whether the panel is open—and applying as quickly as possible thereafter—becomes critical, he adds.
Pros and cons of self-pay
One of the biggest advantages of not accepting insurance is that you eliminate administrative costs related to billing and appealing denials, says O’Hare. You don’t need to submit claims for payment. You—not insurers—decide whether and how often you see patients. You’re not bound by the need to obtain prior authorization or meet stringent documentation requirements. You also avoid potential payer audits and recoupments, he adds.
Another benefit is that you’re not restricted to a contracted rate. This means you can technically charge more than what payers would pay while also offering a sliding scale, when necessary. “With self-pay, you’re empowered to charge what you’re worth without any of the headaches that come along with insurance billing,” says O’Hare. You also avoid awkward conversations with patients about payer denials that can inhibit progress in therapy, he adds.
One disadvantage is that you may not be able to attract clients who are willing or able to pay out-of-pocket, says O’Hare. You may also need to invest more in marketing yourself. “Making a website is fairly easy these days, but nobody is going to see it if it’s on page two of the Google results,” he adds. “You need to think about SEO which can get expensive quickly.”
It’s not an ‘all-or-nothing’ decision
Some therapists may choose to primarily target self-pay clients but also participate with a single payer. “They take one certain plan in the area because they’re happy with the reimbursement rates,” says O’Hare. Others become paneled initially to grow their practice, but drop some or all panels over time due to low reimbursement rates or low patient volumes, he adds.
Others don’t take insurance but are willing to provide a superbill so patients can bill their insurance directly, says O’Hare. Some provide courtesy billing, meaning they file insurance claims to payers so the client can be reimbursed. In both scenarios, clients are responsible for the session fee; however, they may be able to take advantage of out-of-network benefits that pay for a portion of the visit. These benefits sometimes offset the cost of the visits, allowing patients to stay in treatment longer, he adds.
Choosing payers wisely
If you do decide to become paneled, you need to take a strategic approach, says O’Hare. Paneling with every payer isn’t always the best option, though in areas saturated with providers, it may help you remain competitive—especially if you’re the only therapist who accepts a particular plan. O’Hare says to consider these five questions:
- Is the panel open to new providers? If the answer is no, you’ll need to move on—at least temporarily, says O’Hare.
- What’s the contracted rate? How does it compare with the Medicare fee schedule? Ideally, you want to be at 100% or more of what Medicare would pay, says O’Hare. By participating with payers who pay below Medicare, you’re missing out on filling appointment slots with patients whose payers pay more for that same service, he adds.
- How easy will it be to work with the payer? For example, what’s the quality of the payer’s provider relations? Is it easy to reach the payer, and are staff knowledgeable and friendly? What are the payer’s documentation and prior authorization requirements? Is it an onerous process to get approval? Does the payer continually limit the number of sessions? Consider asking local colleagues for input and feedback, says O’Hare.
- What’s the payer’s market share? For example, what insurance do the largest employers in your area offer? Prioritize these payers because their enrollees are your potential customers, says O’Hare.
- Should I be concerned about client deductibles? Most payers have many different plans, with a wide range of deductibles. Since high-deductible plans can’t be attributed to a specific payer, you don’t need to factor this into your decision. You may, however, want to familiarize yourself with the plans that particular payers offer.
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