Getting on insurance panels in a competitive market

[Ipronate]

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Hi all,

I'm looking to start a practice after residency in a competitive region where it is difficult to get on insurance panels. Do any of you have experience with this sort of situation? Do you have any advice or recommendations for resources?

I'm aware that I may not get on insurance panels for a while and will have to be mainly cash pay and medicare- for anyone who has had experience with this, has it been sustainable?

 

[GreenHousePub]

As creflo, from the sounds of thing he's on board with the "direct care" thing.

Also, don't pay for any of those courses from the Direct Care Gurus

 

[icebreaker32]

Have you looked into IPAs?

 

[Feli]

Are there non-competes? (enforceable for physicians, obviously)
Work a job for a year or two to get onto plans and learn a bit.

 

[Creflo]

This is exactly what I ran into - I called all of the carriers and they all told me their networks were closed. So I got on Medicare and kept my overhead low. I had just moved from another state where I was the podiatrist for some ALF's, so to pay the bills I drove to the old state once every 2 months, stayed at a friend's house for about a week at a time. I also worked part time for some pods at my new state (I did notice that when I stopped working for them and opened my own office, some of the private carriers years down the road thought I was on their panel, but maybe it was under the old practice, not sure). Eventually I built up enough Medicare patients to survive in the new state and stop driving to the old state. I've got a thread on sdn that details some of the story. I recently opted out of Medicare, so currently am totally self pay, and it's almost as scary today as it was in the beginning. Followed Dave Ramsey every step of the way (pay off debt asap, don't ever borrow except for home mortgage), it helped that I didn't have a huge student loan burden as I had military partial scholarship. Majored in accounting in undergrad, so had some sense of finances/taxes/business. If you can possibly find a way to do Medicare only, or eliminate any type of insurance plan, it should allow you to stand out among your peers because you will spend more time with the patients and thus have more time to do a more comprehensive job/evaluation. There are some books about doing it, but unfortunately the ones I've read talk about everything but the biggest thing - how to get patients. If you believe the Bible (not trying to push it on anyone, just giving my view here), it has business principles that can guide you. One of them is in Proverbs, where it basically says if you lend to the poor, that God will pay you back. So in my interpretation, if you go provide podiatry services to homeless shelters, God will pay you back. There are many other principles, and I figure I'm not smarter than the Bible, so I try to glean from it.

 

[Feli]

... If you believe the Bible...

 

[Feli]

This is exactly what I ran into - I called all of the carriers and they all told me their networks were closed. So I got on Medicare and kept my overhead low. I had just moved from another state where I was the podiatrist for some ALF's, so to pay the bills I drove to the old state once every 2 months, stayed at a friend's house for about a week at a time. I also worked part time for some pods at my new state (I did notice that when I stopped working for them and opened my own office, some of the private carriers years down the road thought I was on their panel, but maybe it was under the old practice, not sure). Eventually I built up enough Medicare patients to survive in the new state and stop driving to the old state. I've got a thread on sdn that details some of the story. I recently opted out of Medicare, so currently am totally self pay, and it's almost as scary today as it was in the beginning. ...

This is good in general, but anyone who plans to do insurance-based practice definitely wants to hire a billing/cred service to do this stuff (usually $100/hr or less). The stakes are way too high to depend on DIY for this aspect. Use a billing service in the state... they'll know the plans and they'll know some of the insurance company contacts well.

It is not super expensive, and they will absolutely do it better and faster than you (or any almost podiatry office manager). They will likely be able to ask for improved fee schedules, and they might have success with connections at some insurances. It absolutely pays for itself between time saved, being on more plans, frustration dodged, possibly better/more fee schedules. (and this is not to mention that it's very risky to cred oneself while working at another pod office... one fax sheet found or email left open means you're probably fired and in a bad spot).

 

[Hybrocure]

Have you looked into IPAs?

It’s just a temporary fix. You wake up in the morning and feel terrible

 

[HardRoadPaved]

So in my interpretation, if you go provide podiatry services to homeless shelters, God will pay you back.

Geez and I thought scavenging nursing homes bustin crusties was bad enough....

 

[GreenHousePub]

Getting to the homeless shelter to perform 10 "hail formula 3's" but finding out there was 3 other podiatrists already there. Saturation to the max.

 

[air bud]

This is exactly what I ran into - I called all of the carriers and they all told me their networks were closed. So I got on Medicare and kept my overhead low. I had just moved from another state where I was the podiatrist for some ALF's, so to pay the bills I drove to the old state once every 2 months, stayed at a friend's house for about a week at a time. I also worked part time for some pods at my new state (I did notice that when I stopped working for them and opened my own office, some of the private carriers years down the road thought I was on their panel, but maybe it was under the old practice, not sure). Eventually I built up enough Medicare patients to survive in the new state and stop driving to the old state. I've got a thread on sdn that details some of the story. I recently opted out of Medicare, so currently am totally self pay, and it's almost as scary today as it was in the beginning. Followed Dave Ramsey every step of the way (pay off debt asap, don't ever borrow except for home mortgage), it helped that I didn't have a huge student loan burden as I had military partial scholarship. Majored in accounting in undergrad, so had some sense of finances/taxes/business. If you can possibly find a way to do Medicare only, or eliminate any type of insurance plan, it should allow you to stand out among your peers because you will spend more time with the patients and thus have more time to do a more comprehensive job/evaluation. There are some books about doing it, but unfortunately the ones I've read talk about everything but the biggest thing - how to get patients. If you believe the Bible (not trying to push it on anyone, just giving my view here), it has business principles that can guide you. One of them is in Proverbs, where it basically says if you lend to the poor, that God will pay you back. So in my interpretation, if you go provide podiatry services to homeless shelters, God will pay you back. There are many other principles, and I figure I'm not smarter than the Bible, so I try to glean from it.

So has this been worth it at then end of the day? Has it been worth it to your family? Or should you have just gotten a real job?

Edit - I probably know the answer here ....something something Ecclesiastes something

 

[Adam Smasher]

I think the parable of wasted talent (Matthew 25:14-30) is an apt Bible lesson for all of us

 

[heybrother]

I want to touch on something that was said at the beginning of the post - the idea of insurance panels being closed. I've never individually credentialed so I have no idea what its like starting out on your own. I'm also not in an area where I think this would be an issue, but who knows. That said - awhile back a big insurance company created a new insurance in town. My IPA didn't opt to join because they said the rates were terrible and all surgery had to occur at the county hospital. I already operate there. I wondered if this was a missed opportunity ie. to be the only person who saw the insurance in question. I reached out to the insurance company but they refused to send me the rates without an application. I also realized that technically the panel was only open for like 1 month a year ie. there was a specific time period where you could opt/apply to join. Ultimately I called my IPA, they sent me the offered rates, the rates were terrible, and I didn't lose any more sleep over it. But it was interesting to see that the panel was technically closed for most of the year. So - I do wonder, when you hear panels are closed - are they really closed forever or are they just closed during certain time periods.

Since it wasn't really covered above - IPAs or Independent Physician Associations are part of a group of alphabet soup organizations that in someway coordinating credentialing with insurance companies. There are other variations of 3 letter organizations that do different things ie. technically there may be groups that in some way coordinate with managed care. An IPA essentially helps you credential with insurance organizations under their tax number and theoretically the health insurance provides a fee schedule that is beneficial to the group so that the insurance company doesn't have to individually coordinate with individual practices. That said, you can read about IPAs getting in trouble because they don't technically negotiate. They serve as a ...central communication point. The individual doctors within the group though are all competitors so if all the doctors in an IPA decided to coordinate together and say "none of us will take Aetna or whoever and we'll drive up rates" - that would be anti-competitive behavior. In a perfect world by joining the IPA you are simply added to the network through the IPA rather than on your own. Your mileage may vary. My IPA has mostly been a positive experience in that they've arrested the collapse of some of my rates. That said, insurance companies love to tell you that you are in and then they don't update your fee schedule and you spend 1.5 years writing emails saying "hey, I got paid $48 for a 20600 and was supposed to be paid 175% of Medicare".

 

[MicroPod]

Question - if you are credentialed by a hospital and then you switch to private practice or another hospital do you have to re-credential with insurances at that point, or can you just let them know you changed your place of practice?

 

[heybrother]

Question - if you are credentialed by a hospital and then you switch to private practice or another hospital do you have to re-credential with insurances at that point, or can you just let them know you changed your place of practice?

So - you won't just have changed your practice location though. You'll have changed your TIN, you'll have changed your malpractice, your hours. The insurance company is going to want to know what hospitals you have privileges at and how patients are taken care of when you are out of town. I think we talk about this as an awkward process because we wonder could you get punted from the network during these processes, but a part of what the insurance company is doing when they review these sort of processes is making sure you have a real office/location etc where you could take care of people. CAQH is a centralized credentialing location for putting together a portfolio of information about your practice. It has a million questions and they literally will ask you to update things like attesting that you are open at least one day a week. Its a nuisance, but it probably beats doing it at a million locations. The info from CAQH I believe then facilitates your credentialing unless you use a service and even though probably still want to just use your CAQH.

Consider a Medicare DME license ie. DMEPOS. Medicare is legitimately afraid that you don't actually exist and that someone is just dispensing DME fraudulently. They literally send a person to your office to make sure you are real.

 

[PODIATRYCRAZE]

The tip I am providing you is not from experience. It is something I heard from somewhere else and will kind of already be common sense.

Start early. This is location dependent. While you are a resident, some states will let you apply for full license in your last year. Even if your state doesn’t allow it, with the right help it can still be done. If you can obtain it early then you can begin applying for the insurances. The process can be as little as 2 months, to 9 months (even infinity since some never end up getting back to you).

Not sure what your financial situation is like, but if you can afford to start up a little early and employ another practitioner to start working a little before you that can ease you in as well. I heard of a psychiatry resident who opened up a practice while still in residency. She could not do patient care directly through her practice since she was still training. But in the last 2 years, her company had a psychologist, therapists, and other clinicians who were seeing patients. That way upon graduation all of that stuff was already set up.

So in the podiatry scenario, think NP, PA, PT, chiropractor maybe could all be of use. Just make sure you are letting the insurances know that you will eventually be a practicing podiatrist and joining on board.

 

[MMourousias]

If you are planning on starting a practice right out of residency you should set up your business as soon as you can. You will need a lawyer, an accountant and a revenue cycle management company to help you set up your private practice. Be sure to go with a US based revenue cycle management company who will also provide your practice management software as part of their service. This will save you a ton of money. Get recommendations from multiple private practices who outsource their billing. It may seem appealing to try to do it yourself, but there are a lot of regulations that you will not be familiar with. Don't worry about how long it will take to credential with insurance carriers. You will get on Medicare and BCBS relatively quickly. All of the others will take 6 months to a year to get on, so don't worry if the panels are closed. Do not join IPAs if you can help it. While they do manage your managed care contracts, they do change management companies and do close. You are better off managing your own contracts.

 

[SpineDoc101]

If you are planning on starting a practice right out of residency you should set up your business as soon as you can. You will need a lawyer, an accountant and a revenue cycle management company to help you set up your private practice. Be sure to go with a US based revenue cycle management company who will also provide your practice management software as part of their service. This will save you a ton of money. Get recommendations from multiple private practices who outsource their billing. It may seem appealing to try to do it yourself, but there are a lot of regulations that you will not be familiar with. Don't worry about how long it will take to credential with insurance carriers. You will get on Medicare and BCBS relatively quickly. All of the others will take 6 months to a year to get on, so don't worry if the panels are closed. Do not join IPAs if you can help it. While they do manage your managed care contracts, they do change management companies and do close. You are better off managing your own contracts.

Would you mind expanding on this topic a bit? IPAs can change management companies and close?

 

[Hybrocure]

Would you mind expanding on this topic a bit? IPAs can change management companies and close?

Im guessing it works differently if you’re a spine doc and not a lobster