Should You Be in-Network or Out-of-Network With Insurance?

A new year is around the corner and many acupuncturists are looking to boost their practices. One of the most common questions I get is: “Do I need to be credentialed to bill insurance, and what are the best plans to join?” This is a loaded question – but one every acupuncturist ponders.

Let’s start by clearing up a common myth: You do not have to be credentialed or join an insurance plan to bill insurance.

Once you are licensed, you may bill insurance for covered acupuncture services. In fact, many – if not most – plans include acupuncture benefits that do not require the provider to be enrolled. Some plans may even reimburse more to out-of-network providers than to in-network ones. The key exception is with true HMO-style plans, which generally do not offer out-of-network benefits.

So, the real decision comes down to evaluating whether joining a network adds value – or simply limits your income potential.

Remember: No insurance plan pays in-network providers more. They pay less per service, but the trade-off is potential access to more patients. At its core, the decision is simple:

• Does joining a plan allow me to treat patients who would otherwise have no benefits?
• If yes, does the payment rate meet the minimum standard needed to keep my practice sustainable?
• Or does participation simply reduce what I would otherwise earn as an out-of-network provider?

To make an informed choice, it helps to understand the pros and cons of in-network vs. out-of-network participation. Here’s how they compare:

In-Network Participation

Benefits:

• Increased patient volume: Patients prefer in-network providers due to lower out-of-pocket costs and direct billing.
• Predictable reimbursement: Contracted rates make income more consistent.
• Simplified marketing: Your name appears in insurer directories, generating referrals without added marketing costs.
• Faster payments: Clean claims are often processed within 7–21 days.
• Credibility: Many patients perceive in-network providers as more trusted or established.

Pitfalls:

• Lower reimbursement rates: Contracted fees are usually below your standard rates.
• Administrative burden: Credentialing, preauthorizations, and re-credentialing take time and attention.
• Restrictions on care: Visit limits and “medical necessity” rules may limit treatment freedom.
• Audit and compliance risk: In-network providers face periodic record audits and repayment demands if issues arise.
• Delayed or denied claims: Even in-network claims can be held up without perfect documentation and coding.

Out-of-Network Participation

Benefits:

• Higher fee flexibility: You set your own rates and are not bound by insurer fee schedules.
• Greater clinical autonomy: You decide frequency and duration of care.
• Less contractual restriction: No preauthorization or utilization reviews.
• Simpler administration: You can bill directly or provide superbills for patient reimbursement.

Pitfalls:

• Reduced patient volume: Many patients avoid out-of-network providers due to higher costs.
• Unpredictable payments: Coverage and reimbursement vary widely.
• Increased patient collections: Patients pay you first and then seek reimbursement, which can delay cash flow.
• Reduced visibility: You’re not listed in insurer directories, so fewer new referrals.

Strategic Considerations

Hybrid approach: Many acupuncturists join select networks (e.g., UnitedHealthcare, Aetna or strong regional PPOs) while remaining out-of-network status with others. This balances patient access and revenue.

Local market factors: In communities with high acupuncture awareness or strong cash-based wellness demand, out-of-network models thrive. In insurance-dependent regions, being in-network may be essential for patient flow.

Administrative capacity: Clinics with strong billing systems can manage insurance participation more effectively. Solo practitioners with limited staff often do better staying out-of-network.

The Bottom Line

Whether you choose to participate in insurance networks or not depends on your local market, patient base and financial goals. Evaluate your own data, compare fee schedules and make a strategic decision that supports your long-term stability, not just short-term patient volume.

Always remember that participation is your choice. You can join a network, evaluate its value to your practice, and later decide to withdraw if it no longer serves your goals. While termination is not immediate and usually requires advance notice per contract terms, it remains fully within your control.

Editor’s Note: Have a billing question? Submit it to Sam via email at sam@hjrossnetwork.com. Submission is acknowledgment that your question may be the subject of a future column.