5 Pros and Cons to Accepting Insurance

By: Klara Knezevic RD, LD

If you are just starting out in private practice, you might be asking yourself the age old question “Do I accept insurance?” It is a good question, with really no right answer! The decision to accept insurance is really based on your practice model and your speciality.

As a dietitian, there are several different types of insurance that you will see. The two main types of insurance are public insurance and private insurance. Public (or government) insurance includes programs like Medicare and Medicaid. Medicare is provided by the government to individuals who are over the age of 65, or on disability. Medicaid is provided by the government to lower income individuals and is based on eligibility. Private insurance is usually provided by an employer, and includes plans such as BlueCross Blue Shield, Aetna, Cigna, United Healthcare etc. Within the private insurance sector, there are different types of plans to keep in mind:

• Health Maintenance Organizations (HMO): This is one of the most rigid types of private health insurance. A patient’s care is managed by their primary care doctor, and a patient is referred to specialists as their MD sees fit. The patient has the least flexibility in choosing their healthcare providers, and a referral is required to see a specialist. If a patient chooses to see a medical professional outside of their HMO, they are required to pay the full bill.
• Preferred Provider Organizations (PPO): A PPO provides more freedom to the patient when it comes to choosing their healthcare provider. The patient is not required to have a referral from their primary care doctor to come see a specialist. A patient with a PPO insurance can see an out of network provider, but are required to pay the full bill. The patient will then submit the claim to the insurance for possible reimbursement.
• Exclusive Provider Organization (EPO): An EPO also providers more freedom in choosing a provider, and you are not required to have a referral from your primary care doctor to see a specialist. However, unlike the PPO plan, if you see an out of network provider with an EPO plan, you are responsible for the full bill, without likelihood of reimbursement.
• Point of Service Plan (POS): The POS plan is a blend of an HMO and a PPO. You have a primary care doctor that manages your care, and refers you to specialists as needed. If a patient chooses to see an out of network provider, they are required to pay the bill, but can submit to the insurance company for reimbursement.

So that is all fine and dandy, but as a dietitian, what do I need to know about accepting insurance? Well, I am glad you asked. Because, I have the pros and cons you have to consider when making the insurance decision for your practice.

Pros

1. Free Marketing

Once you become an insurance provider, your name will be listed on the insurance website, which means, free marketing! Clients and patients often go directly to their insurance website to find providers that are in network. If your name is listed there, they are more likely to find you!

1. Doctors are more likely to refer

A majority of our client base comes from referrals from doctor’s offices. When Rebecca and our team will meet with doctors to market our services, often the first question they ask is “What insurances do you accept?” We have found that a doctor is more likely to refer to a dietitian that participates with insurance, because his patients are more likely to come if their visits are covered.

1. Will help build your schedule!

With more MD referrals and free marketing coming from the insurance company’s website, you are more likely to have people calling to inquire about your services. With the prospect that insurance will cover their visits (at little to no extra cost to the patient), they are more likely to schedule an appointments with you, which means that you schedule will fill up!

1. Wide client base

By accepting insurance, you will see clients from all different backgrounds and socioeconomic statuses. This can provide to be a challenge, but also fun when counseling! As a dietitian, I see so many different clients, that come from all over the world! I have learned so much about their cultures, and the food that comes with it!

1. Wellness Programs

Often, insurance companies have wellness programs that they sponsor. If you are an insurance provider, these companies may ask you to speak at said events, and pay you to do so!

While there are definitely pros to being an insurance provider, there are cons to be noted as well.

Cons

1. Inconsistent Coverage

Insurance coverage is NEVER guaranteed. Some plans have fantastic coverage, while others fall short with even the basics. Unfortunately, there are few plans where we know with some degree of certainty that we will see payment. Medicare is one of them, however, only if a patient is presenting with diabetes or renal disease. The Federal Employee Program with BCBS is another plan that will cover for any reason, but will only pay for 6 visits per calendar year. One way to ensure a patient has nutrition counseling benefits is to run a benefit check with the insurance company. However, while this is beneficial, it is also time consuming.

1. Delayed Payment

It can take weeks or months for insurance to pay on claims that were submitted to them! Meaning that it can take some time to see compensation for services that you provided. Payment can be especially delay if you are required to resubmit a claim that was denied originally.

1. Troubleshooting May Be Required

There is nothing worse than getting an Explanation of Benefits (EOB) back from an insurance company that has a denial on it. I have spent countless hours on the phone with insurance companies trying to figure out why a claim was denied. Sometimes, it is an easy fix, and you can resubmit the claim right away. However, sometimes an insurance company will require that you provide visit notes, or letters of medical necessity before they cover the visit. And sometimes, there is nothing we can do, and the patient is responsible for the balance. 

1. You Can’t Bill For Time Spent Out Of Session

One of the major downfalls of insurance is that you cannot bill the insurance company for time spent out of session creating resources, answering emails, coordinating care, and any other tasks that may be required to help provide comprehensive care.

1. Additional Help May Be Required

As your practice expands, and your patient load grows, you may find that you spend more and more time submitting claims, checking benefits, and calling insurance companies to troubleshoot claims. You may find that you need to hire additional staff to help with the billing elements of the practice. Whether you chose to hire someone in house (which means you will be responsible for their salary, or hourly rate) or chose to hire a billing company (that will take a percentage of whatever they bring in), this can increase the overhead cost of what it costs to run your business.

If you would like more help learning how to become an insurance provider or how to manage billing for your practice, make an appointment with one of our business coaches today!