Insurance Doesn’t Work for You. We do.

One of the most common questions we receive is: “Will my insurance cover your care?” The short answer is no, and there are many reasons for this which I would like to share with you. 

The following reasons pertain to the business side of things and the complexities of insurance billing. It may be long-winded, but if you would like to know the full context of our decision, read on. If not, skip to the next part B. 

Part A: How to Join the Club

First, becoming an “in-network” provider (i.e., one credentialed with an insurance company), involves a lot of hoops to jump through from start to finish. A provider who wants to bill an insurance company must apply to do so; this is a lengthy process that goes no-where unless you pay a credentialing agent a substantial fee (usually $2-3k). This process must be repeated for each insurance company and each provider in the practice. As you can imagine, this is a significant expense before the first patient makes an appointment. There is usually a waiting period as well after the fees are paid. So before the first pitch is thrown, the cost of doing business has gone up. 

After the provider’s application has been approved and is now in-network, it becomes necessary for someone (provider or staff member) to have to verify each patient’s insurance coverage. While some verification can be done online, the most accurate method is to call the insurance company. If you have ever had to do this for yourself, you already know this takes a long time and usually includes answering the same questions repeatedly. This also needs to be done perpetually to bill the patient correctly: make sure deductibles have/have not been met, apply proper co-insurance percentages, and ensure that the number of visits covered is not exceeded. This can absorb a lot of time, potentially taking away valuable time spent with the patient. Many offices hire dedicated staff for this role, which further increases the cost of doing business.

With the provider in-network and the patient’s coverage details established, the next step is to deliver care according to these coverages and limitations (finally…the fun part). Next, the satisfied patient is sent on their way with some recommendations and a plan of care. All that is left is to bill the insurance company for the care provided so the provider can keep the lights on. This includes sending in exam forms, treatment notes, any pertinent documentation to support the provider’s delivery of care or patient history, and the bill. If the provider has signed a contract with an insurance company, the cost of the delivery of care is set by the insurance company and is subject to change. The rates of reimbursement to the provider also vary for each insurance company, which make business projections and goals very complicated. Additionally, each insurance company may have a different billing submission process—paper, online portals, or third parties—often requiring hiring a billing specialist, either for a flat fee or a percentage of collections. Again: the cost of business goes up just to accept the loose promise of reimbursement for the delivery of care. 

Part B : Our Own Club

I mention all this in order for you to gain a better understanding of how this can take away from the patient experience and increase the cost of providing care. This leads to my next reason: accepting insurance changes the conversations between the provider and the patient. Instead of initially focusing on what the patient’s financial burden will be depending on the limits of coverage, the conversation can now flow from patient concerns, history, past-experiences (good and bad), and then to care. Similarly, you don’t pay first for a good meal. This is how I would expect to be treated at a doctor’s office. This approach to both new and existing patients promotes consideration, professionalism, trust, and putting the patient first. 

The last reason is more of a philosophical one. Insurance doesn’t work for you. It is a numbers game to make money for shareholders and find every possible reason under the sun NOT to pay for the things you think you are covered for. Even with the most diligent documentation, thorough coverage pre-verification, textbook exam, and appropriate delivery of care, I have personally seen insurance carriers deny payment to providers or reimbursement to patients. This often leads to providers taking shortcuts with care to make up for deficits in the bottom line, or patients seeking watered down care options to maximize the coverage they have elected. Insurance coverage really isn’t that good at relieving the financial burden of emergency care, and certainly not good at preventative care. 

For all these reasons, we have decided to prioritize you, not the shareholders. Working for you has been one of the most rewarding decisions of my life, and I would never trade that for anything. To book an appointment, click here.

Here for You indefinitely,

Patrick McCabe DC