Mark Sanna, DC, ACRB Level II, FICC
The expansion of Obamacare has made insurance policies with $10,000 to $15,000 deductibles commonplace. Savvy health care consumers are making more cautious decisions about where to spend their discretionary healthcare dollars than ever before. This leaves many chiropractors struggling with a choice of being a cash or insurance‐based practice. They wonder if the increased demands upon their and their practice team members’ time that come with accepting insurance is a viable business model for their practice future. Many chiropractors facing this dilemma feel that they must choose either cash or insurance as an “all in” or “all out” strategy.
The Either/Or Scenario
Chiropractors who choose to opt out of insurance reimbursement do so because they believe that removing the burdens of dealing with third party reimbursement will reduce their daily level of stress and free them to offer patients more affordable payment options. Many times these practices offer services at reduced fees. Due to their lower fees, seeing a high volume of patients is often the way that these chiropractors can generate a level of income that will support their overhead and lifestyle.
Chiropractors who choose to focus solely on the insurance‐based model of care confront a different set of problems. With increased limitations on chiropractic coverage, including the number of visits allowed, these practitioners often times tailor their patient recommendations to the level of services covered by third party payers. Practicing to meet the requirements of insurance payers takes the focus away from the patient’s health needs.
I’ve seen chiropractors place themselves and their practice in jeopardy because of their lack of knowledge of the significant regulatory and compliance requirements that remain in place whether they decide to accept insurance or not. The “let’s make a deal” payment plans offered by both cash‐only and insurance‐based practices walk a fine line between what is legal and what is not. Offering the same service for different fees is considered a dual fee schedule and is illegal.
Blend the Best of Both
No wonder chiropractors are confused. Let me assure you that it is possible to create a practice that blends the best of both cash and insurance. Your practice can deliver affordable care to a high volume of patients while meeting the requirements of insurance reimbursement. This may be easier to achieve then you may think. The first step is to establish a compliant fee schedule that allows you to accept limited insurance coverage while at the same time offering your patients legal discounts. This can only be done by joining a recognized Discount Medical Plan Organization (DMPO) and creating a cash‐based fee schedule that is published and available to all patients regardless of their level of (or lack of) insurance coverage. A DMPO allows you to blend covered and uncovered services into an affordable payment plan that fits the financial requirements of care into the patient’s family budget. It also allows you to inform patients what their financial responsibility will be from their very first visit. This removes stress from providers, practice team members and patients.
Moments of Truth
Along with compliant patient financial procedures, the blended practice has a system of compliant patient care procedures that begin with a new patient’s first interactions with your practice. How your practice team handles these moments of truth is essential to your success.
Patients make both conscious and subconscious decisions as to how much they are willing to spend when they purchase care from you. You can build the perceived value for your care by creating an extraordinary first visit experience for your new patients. When delivered correctly you should regularly hear the words, “That was the most thorough examination that I have ever received—I feel like I’m in the right place!” To consistently achieve this high level of perceived value requires you to take a fresh look at the services you provide on a patient’s first visit. These include: your consultation and examination procedures.
Build Value with Your Consultation & Examination
New patient procedures begin with the consultation. During your consultation, let patients know that you’ll be listening closely to the answers that they provide to the questions that you ask them while taking their history. Let them know that their answers will guide you in the choice of which tests you will perform and which instruments you use during their examination. Let them know that this allows you to customize their examination to specifically look for the cause of their condition. Custom‐designed items and services carry a higher perceived value then their off‐the‐shelf, generic counterparts. By letting patients know that they will be receiving a customized examination you increase the value that they place upon your service.
You can add tremendous value to your examination procedures simply by recording them with a digital recorder. Inform the patient that you record all of your examinations and get their permission for the recording. Recording your exam accomplishes several goals. Most people don’t like to hear themselves recorded. For this reason, patients tend to be quiet during your examination and this allows you to proceed with your examination without extraneous comments and conversation.
As you examine the patient, call out your findings to the recorder. Rather than the typical silence on the part of the examiner, which can be confusing and unsettling to the patient, you’ll be providing value‐building information. A patient undergoing a Lasègue test may think that you are simply lifting their leg until it hurts. Calling out the finding “Lasègue test positive on the right hand side at 45 out of 90 degrees for L5 nerve root tension” lets the patient know that you have found something wrong with them. This will limit much of what is covered in a traditional Report of Findings. The patient has listened to your Report of Findings during the examination process. This raises the value of the entire procedure and lets the patient know that you are actively examining them to uncover the cause of their problem.
Build Value with Your Report of Findings
I counsel my clients to avoid adjusting their new patients on their first visit. Providing palliative therapies to decrease pain and inflammation is encouraged. Adjusting the patient immediately following their examination decreases the perceived value of your care exponentially. How significant could the patient’s problem be if you determined the cause and applied the correction within minutes of meeting the patient? If you feel that you absolutely must deliver an adjustment on the patient’s first visit, I encourage you to send the patient home for several hours to rest while you review your examination findings and create your plan of care. Have the patient return later in the day for their report.
Having the patient return for their Report of Findings and first adjustment gives your practice team time to verify insurance benefits. You will know the patient’s level of coverage and the doctor will have created an initial plan of care. You can now estimate the patient’s financial responsibility for their course of care and create a payment plan without the stress of having to do it on the spot, while the patient is waiting to receive care. You can deliver a financial consultation to the patient immediately following their Report of Findings.
Begin your Report of Findings by confirming to the patient that your examination uncovered the cause of their condition and that you have the ability to provide them with the care that they need. At this point patients will be concerned with two primary questions: they want to know how long it will take and how much it will cost. The blended practice, utilizing a compliant DMPO fee schedule can make a recommendation for care based upon what the patient needs and not what their insurance does or doesn’t cover. This allows you to give the patient your recommendations for care based upon your estimation of how long it will take for their condition to resolve and not their financial circumstances.
Increase Case Acceptance
Add these steps to your new patient procedures and you will increase the value of your care in the eyes of your new patients. Handling patient finances skillfully, upfront by blending
insurance benefits and cash in a unified payment plan decreases stress and increases case acceptance. Patients are more likely to follow through with your recommendations when their financial commitment has been taken care of in advance when their perceived value of your service is at its highest level.
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