How to Optimize In-Network vs. Out-of-Network Insurance

As an acupuncturist, you might not be billing insurance, but even for those who primarily operate on a cash basis, it is important to have a foundational knowledge of insurance because it can broaden the scope of accessibility to your services. While the essence of acupuncture lies in holistic healing and individual well-being, understanding the nuances of insurance billing also becomes a practical necessity for sustaining a thriving practice.

Let’s examine the different ways that an acupuncture practice might access insurance payments – especially the differences between and how to optimize in-network and out-of-network insurance.

As is common across the health care industry, navigating the complex world of insurance is a frequent source of frustration for both acupuncturists and their patients. The statistics tell a sobering story: about 15% of insurance claims are rejected, a number that has increased 17% since 2019.^1-2 in addition, it costs an average of $25 to handle each rejected claim, so claim errors can add up really quickly.³ Given this data, acupuncturists might be tempted to avoid insurance companies entirely.

Approaching Insurance as an Integrative Practitioner

However, the data from Soundry’s February 2022 Integrative Practitioner Survey paints a clear picture. A significant percentage of integrative providers choose to engage with insurance networks. Specifically, 76% of these providers are in-network with at least one carrier, while 15% opt for a dual approach, accepting both in-network and out-of-network patients. A mere 5% exclusively rely on cash or out-of-pocket payments. Contrary to the popular belief that many health care professionals are moving toward a cash-only model, the reality for integrative practitioners is more diverse.

Considerations for In-Network Participation

Being in-network with an insurance company means negotiating a contract with and agreeing on specific rates; and most importantly, being listed as an in-network provider on insurance payers’ websites and network. Being in-network carries some advantages: it can translate to a steady influx of new patients, which is invaluable for practice growth, and can open the door to referrals from other medical providers.

While there are many positive benefits to being an in-network provider, there are also some drawbacks. Dealing with insurance billing can be a time-consuming and complex endeavor, often laden with administrative hassles. The process of becoming an in-network provider is accompanied by tedious paperwork and credentialing requirements. Once you are in-network, there is limited room for negotiation in terms of payment rates.

Optimizing In-Network Participation

If you do decide to go in-network, do everything in your power to make the insurance companies work for you. First and foremost, always keep a copy of your contracts on hand to ensure you are being paid as agreed. Keep tabs on how long it has been since your contracts were last renewed, as outdated contracts can result in lower reimbursement rates.

When the time comes to renegotiate your contracts, go into the negotiation with as much information as possible: talk to peers in your area, know how many other acupuncturists practice nearby, and identify whether any of the services you provide are unique in your geographic radius.

If it’s been a while since you last negotiated rates with your insurance company, research how the cost of living has changed in the intervening period, and use that change to justify your request for a commensurately higher set of rates.

Considerations for Out-of-Network Participation

Out-of-network participation brings its own set of merits. If you are out-of-network with an insurance company, you still bill that company for your services, but are not contracted directly with them. This provides some ability to offer affordable care to patients who have coverage of acupuncture services through their health plans.

Out-of-network providers generally enjoy higher reimbursement rates, and no credentialing process is required, although some insurance payers still require a provider to register as an out-of-network provider on their websites. Out-of-network providers also have more flexibility in the billing process. They can simply still collect their self-pay rates and provide a superbill to the patient to file their own insurance; or ideally, they can submit the claim for the patient and provide a discount to the rate the patient pays.

Nonetheless, out-of-network participation comes with its share of challenges. Patients may face financial hurdles. Higher costs are a common issue for patients due to higher out-of-network deductibles and out-of-pocket maxes. Moreover, out-of-network practitioners might face restrictions on the number of sessions they can provide and the rates they can charge, depending on the insurance payer. Furthermore, payments may be sent directly to the patient, necessitating additional communication and coordination.

Optimizing Out-of-Network Participation

To maximize your out-of-network participation, consider several key factors. Thorough benefit verifications are crucial, as online eligibility checks can be particularly inaccurate for acupuncturists. Deductibles are often significantly higher for out-of-network patients, so understanding the remaining balance and advising the patient accordingly is vital. Online portals may not have up-to-date information on deductible balances, session maxes or referral requirements.

If you do decide to go out-of-network, balance billing is worth considering. This involves filing an out-of-network claim on behalf of your patient and billing the patient for the balance not covered by insurance. This approach can significantly improve the patient’s experience and ease of payment. It’s worth noting that practitioners who provide balance billing often experience better patient retention and more recurring visits.

Key Take-Home Points

The decision to be in-network or out-of-network for an acupuncturist will hinge on the carriers in your area, what rates they’ll offer you, and how many patients in your area use a given insurance carrier. Aside from commercial carriers, acupuncturists should also consider the Veterans Administration (VA) as a potential in-network provider, which has good coverage of integrative specialties.

Ultimately, understanding and choosing to participate in insurance networks can be critical to maintaining an accessible and thriving practice. However, by delving into the realm of insurance, acupuncturists not only enhance the financial viability of their practice, but also contribute to the integration of holistic approaches into a broader swath of the health care world.

References

1. Politz K, Rae M, Mengitsu S. “Claim Denials and Appeals in ACA Marketplace Plans in 2020.” KFF, Feb. 9, 2023.
2. 6 Keys to Addressing Denials in Your Medical Practice’s Revenue Cycle.” Medical Group Management Association (MGMA), March 18, 2021.
3. Mills T. “Why Getting Claims Right the First Time Is Cheaper Than Reworking Them.” Physicians Practice, Sept. 9, 2019.