Podcast Episode 9: In-Network vs Out

Enlightened Practice Podcast

In-Network vs Out. Or Both? In this episode, Dr. Braslow and Dr. Kagan talk about the pros and cons of being an in-network clinician, as they explore the financial, marketing, and administrative challenges behind the decision. If you want to learn more about this important topic, don’t miss this episode!

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Transcript of the podcast

Ken: Hi, Kari.

Kari: Hi, Ken.

Ken: So, today we’re going to be talking about pros and cons of being an In Network Clinician for your clientele. I’m curious to hear your thoughts what your experiences of being out of network. Do you have clients who push you to be in network or does it even come up? As you get going, what’s it like?

Kari: Well, in the bay area where I’m located, I think it’s very common for a therapist to be out of network. So, I don’t think it comes as a surprise to many clients to hear a therapist is out of network. I do think in other parts of the country it’s different I imagine. So here I don’t think it comes as a surprise to clients and especially for certain types of insurance like PPO plans for example, clients can get reimbursed for out of network services. And that I think kind of satisfies both the client and the therapist’s needs. I don’t have to deal with downside of insurance on my end and the client also gets reimbursed. It’s not as simple as if I was an in network provider for them. There’s a couple of other steps they have to do to get reimbursed but they end up getting covered through insurance one way or another. So I think that it’s a nice middle ground for both me and the client. 

Ken: Um hmm. You know, I think, patients are used to their primary care team taking insurance but they don’t realize how many resources are in that physician’s office that just goes to the process of insurance. And therapists and many psychiatrists must be part of a big group. You’re not typically set up to process all that administrative work. I mean, that could become a third of your hours or half of your hours. It’s just not feasible to sustain a private practice at that rate. How do you find your clients do with the process of getting reimbursement? Is that hard for them or is it routine? 

Kari: It becomes routine. I think the first time is a bit more challenging and I do have some tips for helping clients, certain questions that they can ask their insurance that can streamline the process for them if they just simply have a code number that they can give their insurance to get information on whether or not their insurance reimburses out of network, for example. So, I think the first time clients go through it can be a little tricky because I need to figure out what forms to fill out and all that kind of stuff, but once you do it once it becomes pretty routine. The other thing too is that there are apps these days that help clients get reimbursed out of network. I don’t know if I should say the name of one of these apps I know, but there are ways that make it for either it’s free or a very low, low, low cost that you can basically upload your statement through this app and they will do it for the client. So there are ways of making it even easier but usually it becomes routine. 

Ken: Yeah. One of the things I tell patients, they ask like a hundred questions on the form but for like ninety eight of them you can put “see attached.” And with the super bill that my patients can generate in the portal or that I generate for them, it has all the codes, all the ID numbers. And I encourage them in the beginning of the year, set up a couple of envelopes for the whole year and photocopy the cover sheets. And you don’t need my signature even though it says you need my signature, you don’t. 

Kari: Right, yeah. 

Ken: I’ve never had to claim that process without it. So they kind of help them see that this is annoying but it costs them a few minutes and it’s not worth leaving their reimbursement on the table just because it’s a process, not that they have to do it every week though. 

Kari: Right. 

Ken: So, what’s your sense of, by it being out of network, do you get insurance companies who are reimbursing your clients requesting records, or saying you’re taking too long, or do they stay out? 

Kari: In my experience, they stay out. There are no limits that I’ve encountered that I can think of at the top of my head right now. They don’t put any limits in terms of number of sessions you can meet with a client if they’re out of network or anything like that. That’s not to say that doesn’t exist but it hasn’t been in my experience. So, that’s part of the advantage of being out of network, just not having to deal directly with the insurance companies, like you said it can be a hassle and time consuming on our end. And it doesn’t seem to be that they need to really be involved once you’re out of network. What’s your experience been there?

Ken: Yeah. For the folks I see out of network, I never had an insurance company question the treatment at all. When I’ve been in network I have had them, when I was doing therapy and meds in network that seemed to take them by great surprise and they asked me to do treatment reviews with them. And sadly, even though I think the concept of treatment planning is very good and should be incorporated within therapy, I don’t think it’s in a patient’s interest for me to be doing that with the insurance company. I didn’t like that intrusion in the patient’s care. I don’t think the insurance company really cares about the patient’s wellbeing. I think the meta-message the whole time was, finish up. They were not going to deny care, they were just going to do treatment reviews frequently enough that you’d get tired of it, so, plausible deniability kind of thing. 

Kari: Right. 

Ken: So, I do see patients in network and some in-claims are much easier than it used to be because it’s just a few clicks. And seeing patients for meds, I’ve never had them question my med plan, again with therapy… but unfortunately, that led me to not want to do therapy with the pairs that I contracted with, and that’s just kind of how it goes. I would say, 98% of the time taking insurance is fine. I mean insurance company cheques don’t bounce, they pay. They have laws on most dates on how long they take to payout. Unlike patients who sometimes can take many, many months to pay and their cheques do occasionally bounce. Insurance companies are pretty above board with all of that, but it’s the 2% of the time where a claim is denied because the patient has a new ID number but they didn’t realize or they didn’t tell me. Now I’ve got to go resubmit it all over again, or there’s some limitation treatment wise and it’s really important before you take out, if you are going to be in network that in your policies you have a provision for what to do when insurance won’t pay. What I tell my patients in the policies is, I am taking insurance as a courtesy, they are a third party, but whether or not they pay this is my professional time and services are still being rendered. So, payment is still expected whether or not the insurance company makes a payment. 

Kari: Right.

Ken: Often, it’s really useful to run a patient’s insurance coverage, even if the patient knows the insurance coverage, for the clinician to run it because the comfort of a deductable has changed over the years. It used to be a deductable was $100 or something and now they’re in the thousands often. So, patients may think, whether they’re in or out of network, they may think they have great coverage and maybe they do once they tether a deductable but they don’t always understand what that deductable even means and that even if they’re getting credit for paying for the sessions they need to know an estimate beforehand of how much a session will cost them. So, for my in network patients I spell out for them how much an in-take session would cost them and how much my negotiator rate with the insurance company is, so that way they know what their out of pocket cost will be. Same thing goes for no-shows. 

Kari: Right.

Ken: I don’t even bother submitting insurance claims for no-shows. They just won’t pay them. And this is really important for college students and teenagers to understand that their parents most likely are going to get stuck with the bill. In the college student mind anything is changeable at the last minute. It’s part of the joy of being in college. 

Kari: Yeah.

Ken: And even though I have college students sign off on policies, I don’t know to what degree they really get it. 

Kari: Right.

Ken: So, whether it’s in network or out of network, I make a special point of explaining the concept of the no-show. They’re not paying for the session. They’re paying for the reservation of the session and the session, they go together.

Kari: Right. 

Ken: I would also say with in network I often have patients call the insurance company just t make sure their coverage is still active even if I’ve run it. I just want to reduce the odds that a claim is submitted and rejected right away. There’s no better way to interfere with treatment than to have a payment issue with the insurance company come up. And then puts a clinician in a real bind if you’re just starting care but insurance isn’t paying, you want to continue what’s in the best interest of the patient but it’s really challenging then to navigate those conflicts of interest.

Kari: Right, yeah. I’m also curious in your experience especially early on since you’ve been both in network and out of network, do you find that you had more like steady flow of referrals being in network, that you would have a more consistent flow from there as opposed to out of network?

Ken: When I started in private practice, the day I hit the insurance company’s website, my listing went live, the phone started ringing off the hook.

Kari: Wow! 

Ken: It was quite powerful to a point where I quickly became overwhelmed. I didn’t have an assistant at the time and I didn’t have many systems in place to handle that at the time. 

Kari: Yeah. 

Ken: So, for sure it was good in building practice and that’s part of what insurance companies. That’s part of the deal they’re making with you. They’re doing the marketing essentially for you. They’re bringing a whole network to you.

Kari: Right. 

Ken: That is value and that is reflected in their rates somewhat. I will say, one other advantage I found with having such high volume to begin with was that I met a lot of patients’ therapists that way because I wanted to of course have good treatment planning and I would talk to them and we’d get on the same wavelength. And then they would start referring me patients because we had a relationship and some of those patients were in network of course because they were in network, but some were not in network.

Kari: Yeah. 

Ken: So, having a blend of in network and out of network was a nice way to start. It allowed me to build my practice and I really enjoyed taking insurance and having people only have to pay $10 for a session that felt nice. 

Kari: Yeah.

Ken: And 98% of the time it was actually a good fit, especially for meds where it gets tricky at least for psychiatrists is the therapy portion. I don’t think insurance companies want psychiatrists doing long-term or even short-term therapy. 

Kari: Okay.

Ken: So that’s something to keep in mind. But there are some real benefits to it. The process of working with them has become much more automated and electronic over the years. So, at the beginning I was printing out claims and stamping envelopes and that was unfortunate and that’s not an issue now. 

Kari: Yeah.

Ken: That said, I enjoy knowing that if somebody is seeing me out of network that it’s highly unlikely that the insurance is going to want to see their records. I cringe when I’m in network and insurance companies ask to see the records. I never know who is going to see that information and what they’re going to do with it and where it’s going to be stored for eternity. 

Kari: Yeah.

Ken: And they’re not doing it for the patient’s best interest. I think that’s the part that makes me cringe the most about that arrangement. I can understand that. I get that they have the right to request it. I just don’t like to put patients in that position. 

Kari: That makes sense. 

Ken: If you think about kids, they have no control over this process as it is. And they’re not able to give their consent in any meaningful way. What if they’re a 7 year old and their records are with the insurance company for life. It just doesn’t feel right. 

Kari: Right, yeah. 

Ken: So, that’s some of the pros and cons of working in network. They do build your practice and I would say, if you’re going to consider doing in network, give it time before. There is no such thing as a quick negotiation with an insurance company, unless you’re just going to sign on the dotted line. 

Kari: Right.

Ken: I mean, guaranteed you’ll send in your paperwork and then they’ll misplace it or they’ll need something you already sent them. And maybe they only review it once a month because they get ten thousand applicants and they’re trying to be more efficient. So, it can take months just to get credentialed and then the insurance contract negotiations begin. Of course, they’ll always offer you lower rates to start. And if you’re in a rush you might be more likely to take them.

Kari: Right.

Ken: And if you have the luxury of time you can push back and negotiate and even walk away. There were some negotiations that I had with insurance companies that went on for quite some time then I said, this is just not feasible. I can’t sustain a private practice with the rates they’re looking to reimburse or with what they’re expecting of me. My personal style, I really like to work closely with patients and families and I cannot do a ten minute med check. It’s just not in my makeup. But there are some people who can do that then insurance can be a really good fit and then of course we talked about the therapy challenge. 

Kari: Yeah. 

Ken: Well, any other thoughts about in network versus out of network dilemma that comes to mind?

Kari: No. It was actually really informative for me as an out of network provider to learn more of the in network process and it definitely seems to have advantages, especially from a building your practice perspective. Oh, I guess just one other quick question, is it relatively easy to transition once you start as an in network therapist and if you’re considering transitioning to out of network or at least partially out of network. Is that a pretty straightforward transition? 

Ken: That’s a great question. So, you have to give the insurance company and your clientele at least three months notice typically. So, if you’re thinking about it, really think it through clearly but get it going because that three month clock is a bit of a long window. I will say, I did transition out of one or two payers and I would tell patients and some of them said, sorry I won’t be seeing you anymore and I totally understood that. And I would try to give them referrals of colleagues I knew in network. 

Kari: Hmm.

Ken: And some would say, okay, I get it. Like you were saying earlier about, at least in certain locations expecting most clinicians to be out of network and they stuck with me once I transitioned to out of network. And that was nice that we could have that relationship. 

Kari: Yeah.

Ken: It’s not like everybody is going to come along out of network, but it’s not like body will.

Kari: Right. 

Ken: And then you can always go back in network. I’ve done that with one insurance company also. 

Kari: So many options. 

Ken: Yeah. That’s the good news. There’s lots of insurance companies, lots of payers. You don’t have to sign on with every single payer. So, I would say if you are thinking of going that route, find out if you can by talking to colleagues about which payers have the biggest market share in your geographic area. For example, in the bay area it’s the blues. The blue shield and blue cross that tend to have the most market penetration. So, if you’re looking to build a practice those would be the ones to go with because you’re going to hit the widest audience. On the flip side, because of that they pay less than the other insurance companies. 

Kari: Right.

Ken: So, you have to prioritize, pick what’s the higher value for you. 

Kari: That’s really good advice. 

Ken: Yeah. Well Kari, it was nice chatting. Looking forward to seeing you soon and continuing the conversation.

Kari: Yeah. Thank you. 

Ken: All right, take care. Bye, bye. Kari: You too. Bye.

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