Insurance: Take it or leave it?

Whether you file patients’ insurance claims or not, there’s one thing virtually all providers can agree on — dealing with insurance companies and claims is typically a huge, frustrating, time-consuming hassle.

Part of the “do I or don’t I” question has a lot to do with your specialty, how many (or how few) of your patients have insurance that you accept, and thus how much value you receive from the investment in negotiating with payers.

In addition, as health insurance premiums, copays and deductibles have risen and jobs lost that were tied to patients’ insurance availability, a growing number of patients have felt forced to roll the dice on even having health insurance — knowing full well that a major injury or illness could bankrupt them and their family. Today, fewer of your patients may have insurance than you think. Is it still worth the hassle for you to qualify to accept it, and all of the claims filing and payment delays, or are you doing those administrative tasks for a dwindling part of your patient base?

Also, insurance coverage can put limitations or requirements on the types of care you can be authorized to deliver and, of course, the level of compensation. Many providers are saying that insurance requirements can actually be a roadblock to cost-effective healthcare, due to its requirements for tests, co-pays, “step” therapies that have already failed with that patient, or other issues that constrain you from delivering what services you feel are in your patients’ best interests.

And then there’s the hassle factor. While they share certain similarities — such as standards meant to “reward” what’s considered high-quality, high-value care — there are nuanced but important differences between the requirements of each insurance company and even down to each plan. Unless you have experienced staff and the right information tools, qualifying for the most-popular plans in your area can be staggering, let alone filing claims and fighting rejected ones.

Documentation time spent for each patient visit can also be substantial. One report that collected data from more than 20,000 physicians across nearly 30 specialties described the time physicians are spending on documentation to (hopefully) satisfy the insurance companies for payment as “mind-blowing.” Nearly a third of physicians said they spend 20 or more hours a week on paperwork and administrative tasks. In all, 70% of survey respondents said they spend at least 10 hours a week or more.

Documentation to meet insurance programs’ requirements also means that providers typically must spend more time in an often-too-short office visit looking away from the patient and onto their computer, furiously working to document everything that each payer requires. It may — or may not — lead to delivering evidence-based care and receiving optimal insurance reimbursement, but it doesn’t contribute to a positive patient experience and may even negatively impact clinical outcomes because of a multi-tasking provider.

So, which way do you go…accepting insurance, or going to a direct-pay-only basis? Here are a few things to consider:

1. Assess the pros and cons

How well do the insurance plans you cover truly cover your costs and contribute to your bottom-line financial goals? For all of the investment of time and effort, is it truly worth it for all of the administrative hassles, versus considering a shift to a cash-only or direct-pay basis? What’s the direction of reimbursements for the types of services you want to deliver…up or down? Covered or not??

Also, do you work off of referrals from other providers? That may require you to accept the same insurance plans that your referring providers are accepting, so should be taken into consideration.

2. Assess your patient population

Examine the percentage of your current patient base — as well as those you’re planning to target as part of your growth plan — that you might lose if you stop accepting filing insurance claims and assignment. You may find that whether or not you accept insurance may only impact a small part of your patient population and may not be worth the time, effort and cost. If that’s the case, you can consider a cash-based pricing structure similar to what you’re already receiving from Medicare, Medicaid and other plans. It’s definitely a lower amount, but you should assess the value proposition when taking the costs of accepting insurance into account.

3. Analyze your costs

Are there things in your expenses column that you could cut or do differently whether you accept insurance or not? Perhaps a smaller or lower-cost office location(s)? Remember…a shift in location may also lower your patient volume as well. Examine your lease or ownership, traffic flow and volumes, and estimate what percentage of patients you might lose (or gain!) if you relocate or shrink your practice’s physical footprint or service offerings, unless you’ve moved to a remote-services basis.

Another cost that can add up — and can slow reimbursements — is whether you use a clearinghouse to review medical claims for errors and help ensure the claims are correctly processed by the payer. Their fees can certainly add up.

That’s why users of intakeQ’s practiceQ™ practice-management solution enables providers to internally submit claims. It can easily submit claims and receive ERA (Electronic Remittance Advice) from within practiceQ, reducing costs as well as time lost from delayed reimbursements and the many frustrating hours spent fighting rejections of insurance claims and resubmitting them. The data collected in practiceQ feeds directly into the integrated claims-submission process.

As you undoubtedly know, an ERA is an explanation from a health plan to a provider about a claim payment. An ERA explains how a health plan has adjusted claim charges based on factors such as:

• Contract agreements
• Secondary payers
• Benefit coverage
• Expected copays and coinsurance

All necessary if you’re accepting insurance. And all delivered via practiceQ.

Ultimately, it’s your choice

The pandemic hasn’t just had a negative impact on patients; it’s been hard on many practices as well. Whether due to stress overload or temporary closures, the burnout of providers leaving the field is real and growing. In the U.S., especially with a growing, aging population, that adds to the estimated shortfall of more than 120,000 primary and specialty physicians by 2034 (PDF), from primary care to specialists including psychiatrists. Added to that approximate shortfall are those allied health professionals in physical therapy, occupational therapy, massage therapy and behavioral health to name a few, according to the U.S. Health Resources & Services Administration. This combined gap in growing population needs and health service providers may make some of those even less inclined to accept insurance, or perhaps more willing to consider adding tools such as practiceQ and intakeQ’s comprehensive online forms to streamline their processes and costs while differentiating them as a patient-friendly practice versus the competition.

It’s your choice — in accordance with local laws, jurisdictions, licensing requirements and other factors — whether or not you choose to accept insurance. There are many points, including those in this blog, for each provider and practice to consider, both for their patients and their business.