Selecting Your Game Partners

EPISODE SUMMARY

Are you selecting insurance payers based on hearsay, hoping that more volume automatically means more revenue? You're not alone! In this episode of The Claim Game, Jeremy and Kathryn Zug dive deep into the strategic art of payer selection, dispelling the myth that simply paneling with everyone will lead to a thriving practice. They break down how to align your insurance choices with your long-term practice vision, starting with defining your unique "insurance mix" and clarifying your practice goals.

Discover three common and profitable approaches to insurance mix:

* The Lean Plan: Focuses on maximizing revenue by working with the fewest possible high-reimbursing in-network payers, coupled with private pay clients.

* The Focused Plan: Tailors your payer mix to serve specific patient populations (like Medicare or TRICARE recipients) while balancing profitability with your passion for patient care.

* The Hamburger Plan: Combines in-network high-reimbursing payers with intentional out-of-network billing, offering flexibility but requiring careful administrative management.

Jeremy and Kathryn emphasize that fewer payers can often be better, leading to reduced administrative burden, more control, easier scaling, and ultimately, better patient relationships. They also share critical insights on navigating the financial implications of payer issues like Change Healthcare and TRICARE transitions. Plus, don't miss the inspiring case study of Dr. Eleanor Vance, who built a thriving practice by strategically focusing on a single, dominant payer.

KEYWORDS

Payer Selection, Insurance Mix, Credentialing, Revenue Cycle Management (RCM), Reimbursement Rates, Administrative Burden, Cash Flow, Claim Denials, Patient Registration, Eligibility and Benefits (E&B), Payment Posting, Aging Follow-Up, Claim Submission, Practice Goals, Profitability, Superbills, In-network, Out-of-network, Patient Relationships, Practice Growth.

TAKEAWAYS

Strategic Payer Selection is Crucial: Don't base your insurance choices on hearsay or the belief that "more is always better." Instead, strategically align your payer mix with your long-term practice goals.

Lean is Often More Profitable: Working with a small number of high-reimbursing in-network payers, supplemented by private pay, can lead to significantly higher average reimbursement rates and a much lower administrative burden.

Every Dollar Counts: Even a small difference in per-visit reimbursement ($5 per appointment) can translate to tens of thousands of dollars in annual revenue for your practice.

Mind Your Out-of-Network Strategy: Courtesy billing for out-of-network patients can dramatically increase your administrative burden and expenses. Consider collecting 100% upfront from the patient or utilizing superbills with the reimbursement assigned directly to the patient to avoid chasing these claims.

Prepare for Inevitable Delays: Industry-wide issues (like Change Healthcare or TRICARE transitions) can delay payments, but they rarely mean lost revenue. Maintain a healthy emergency fund and a tight financial policy to weather these periods.

Balance Passion with Profitability: The "Focused Plan" allows you to serve specific patient populations aligning with your passion, but it requires careful caseload management to maintain financial health.

Fewer Payers, Greater Control: Limiting your in-network participation provides more control over your private pay rates, simplifies scaling, and allows for deeper understanding of payer policies, leading to more accurate eligibility checks and stronger patient relationships.

Research is Your Ally: Thoroughly research potential payers by consulting colleagues, scouring insurance websites, and utilizing data companies (like Serif, Clarify Health, and Trek Health) to evaluate market dominance and rates.

Internal Reflection Matters: Beyond external data, consider how a payer will impact your practice's time, cost, workload, and team morale. Choose partners that align with your overall well-being and practice vision.

Prioritize Working On Your Business: A strategic approach to payer selection reduces administrative stress, freeing up your mental energy to focus on improving your clinical services and growing your practice.

RESOURCES

Episode 1: Introducing the Board Landscape: Missed the initial setup of The Claim Game board? Catch up on the six RCM domains with