EPISODE 404: In-Network, Out of Network, and Cash Practice Essentials

Hey, chiropractors. We're ready for another Modern Chiropractic Marketing Show with Dr. Kevin Christie, where we discuss the latest in marketing strategies, contact marketing, direct response marketing, and business development with some of the leading experts in the industry. 

Dr. Kevin Christie: [00:00:00] Hey docs, welcome to another episode of Modern Chiropractic Mastery. This is your host, Dr. Kevin Christie. And today I am bringing Brandy Brimhall on to discuss certain things like insurance, credentialing, billing, coding, how to optimize being an in network provider and the systems and organization around that, how to have checks and balances with your billing.

Things to consider if you are in network or if you're out of network, but you're billing insurances, or if you're just cash. So no matter what type of practice you run, you're going to learn a lot of information from Brandy during this episode. The first half of this, we do dive into a lot of in network insurances and some best practices with that.

And ultimately, you know, how to logistically make this work for your practice. And then we segue into out of network insurance is where you accept insurance, but you are out of network and you do bill for the patient. Some of the [00:01:00] things you need to look out for with that. And then lastly, we do dive into some of the details of cash practice and some of the pros and cons of all three of those types of scenarios that we discuss.

And as you're going to see from this episode, Brandy really knows her stuff and is a wealth of knowledge and a great resource for many chiropractors on the whole revenue cycle. And she defines what she means by the revenue cycle. And there's many points within the beginning and end of that. And her and her company, uh, can help you out with that no matter where you're at.

So without further ado, here is my interview with Brandy Brimhall.

All right. Welcome to the show, Brandy. I really appreciate your time today. I'm excited to dive into all things credentialing and the like, uh, before we dive into that, tell us a little bit about yourself personally and professionally. Sure. So, uh, just like we just started talking about a few moments ago, I am from Colorado and I am still located here, uh, doing the credentialing and, and really everything [00:02:00] to do with the revenue cycle system.

Brandy Brimhall: It's been a passion of mine for a little over 25 years now. So, uh, because of that, I have gotten certified, as you might know, in credentialing and coding and collections and auditing and billing, and I've spent the last 25 years helping clinics in lots of different ways with that area of their practice.

So this is really the summary of the professional side. On a personal side, I have 13 year old twins, and any time I'm not spending time working, which is the majority of the time I'm doing twin stuff. like the rest of us do that have kids at that age. Yeah, it's two jobs for sure. That's for sure. Um, perfect.

Dr. Kevin Christie: And so if you could actually define for me the, the revenue cycle, what would that look like from beginning to end? Yeah. So we often think of it as, well, we enter our patient claims, submit them and then post them when the insurance comes back. But I think that's where we have an oversight initially [00:03:00] because the revenue cycle really starts.

Brandy Brimhall: When the patient contacts us to initiate care or to inquire about care in our office. And so that's when we're collecting information on. They're a payer if they have one, making the determination if it's a payer we're submitting to and then, you know, to, to expedite the processes or the steps or then doing the data entry and setting up the patient and the payer for billing or reviewing the claims once the charges are entered to make sure that they're correct for coding with modifiers, the patient information, the payer information, all of those things, submitting the claims paper and electronic.

Following them through the clearinghouse to make sure our rejections are clean all the way through the receipt and review of the EOB to make sure the claim is process properly. And then of course we post it accordingly if it is and if it's not, what are the next steps that we're taking in order to, to, uh, get access to that money that we, you know, if it's an appeal or resubmission or correction or whatever.

So that's really the sum of it. [00:04:00] And beyond that would be our patient receivables as well, making sure we're collecting over the counter from our patients and having good processes with patient statements where that applies. So that's the sum of the revenue cycle system end to end. And all the way at the very top of that, as far as insurance is concerned, is making sure our business and our providers are properly credentialed and enrolled so that we are eligible to submit to the third party payers without issue.

Dr. Kevin Christie: Yeah. And I get, there's a bunch of questions I want to tackle from that. But the first one here is, are you seeing like a lot of providers have. Essentially like this black hole in their billing where, uh, they, they can't keep track of, uh, denied claims, uh, trying to reprocess and they're, they're just losing money that they may not even know of.

Brandy Brimhall: Yeah, and I would even say that it's not even necessarily in just one place. Pretty much all the time, right? So you know how the docs we, we educate our patients on interferences in our nervous system, right? So we're going to evaluate the patient and [00:05:00] identify and then determine the path forward, make the recommendation of a treatment plan to minimize or remove those interferences in the nervous system.

Otherwise, the patients have their symptoms and conditions that will continue to progressively worsen over time. The same thing applies to the revenue cycle system. If you would look at it that way. And just look at all of the moving parts of the revenue cycle system. And so one of the things that I do all the time is help clinics to identify the interferences in the revenue cycle system so we can determine the fastest pathway to minimize or remove those interferences through the multiple moving parts of the revenue cycle system, like I mentioned before.

So to your question, Absolutely. There's certainly a black hole, always weak areas and clinics where we just either don't know, excuse me, or don't have the time to get to the things that are really our pain points in the clinic. And because of that, we find ourselves just constantly having a deeper hole [00:06:00] to dig out of.

Dr. Kevin Christie: And, um, one of the things we had, uh, uh, we do coaching calls on different topics and our clients. And we did a whole call on the difference between service and hospitality and service is something that you expect, right? You go to the restaurant and you expect to be, uh, seated. You expect to have a waiter, waitress, things like that.

There's, there's essential. service. You expect your steak to be cooked, uh, the way you wanted to. And then there's hospitality, which is going above and beyond. But one of the things that, um, was discussed is how, unfortunately, um, if, if you don't have proper service, it can impact your hospitality, right? You could, you could, uh, theoretically, uh, have a practice that has amazing patient experience and Very hospitable, friendly.

It's, you know, uh, you serve coffee in the waiting room, right? All the nice niceties of hospitality, which we'd love to have. But then if you have issues within your [00:07:00] service, it's going to impact that. And no matter what the, the hospitality was on point, but the service was a problem, right? It's the same thing.

If I go back to the restaurant analogy, uh, that even Jay, this is a do this with Jay Greenstein, but. Uh, if you go to that restaurant, the hospitality is great and they're super friendly, but your steak is just terrible and isn't cooked right ever, you're just not going to go back there. Um, and I think I want our audience to think about this is that if you don't get this right, what you're talking about, you're going to have a lot of opportunities to aggravate a patient based on the service of dealing with the insurances.

Are you seeing that a lot in some of these practices? Yeah. Yep, absolutely. In fact, 1 of the things that I cover in any time I'm lecturing on the revenue cycle system is that our patient relationships are impacted 1 way or another, regardless of what we're doing or not doing in our clinic. And then I also would add that there are [00:08:00] typically 2 primary reasons and granted, there's others that always would apply, but there are 2 primary reasons a patient would discontinue care.

Brandy Brimhall: 1 of them has to do with someone of that hospitality that you mentioned, which is the overall patient experience. In the clinic, the other one has to do with their finances and what's being communicated or not communicated or managed, or how it's managed for them in your clinic. And you can lose patient credibility really quickly, and it's very hard to get back.

And, of course. Especially with our new patients, as we know, you only get 1 time to make a 1st impression. And this is an area that really should constantly be reevaluated all the time with clinics, just to make sure that it's truly a streamlined as it can, because, you know, the revenue cycle system is imperfect.

It's always going to be imperfect. There are things that are going to happen. And we know that. However. If we really do our best to keep our fingers on the pulse of our internal processes and systems and communications, we really can minimize a lot of those things that [00:09:00] happen that impact that service experience that patients are having as it relates to the revenue cycle system in our office.

Dr. Kevin Christie: Yeah, and what are a few of the things that you see that frustrate people? Uh, not having insurance verifications collected in time or not having them collected correctly. So the clinic is out of network and we've accidentally collected in network benefits. Now we've miscommunicated with the patient, miscollected from the patient and have to go to them to send another statement.

Brandy Brimhall: Um, determining that some services that we thought were covered now are actually covered under a different umbrella under the policy. So the patient has an additional copay deductible coinsurance and things like that. So, those are the types of things all the way at the top of the stream moving downstream.

It would be inefficiency in patient statements, not getting them for long periods of time when patients call in or come in with questions on their statements. The uncertainty and lack of confidence and being able to explain how the balance arrives to what it is Those types of things are [00:10:00] definitely super impactful And you know, we we build relationships with our patients and that certainly anything related with money Is it going to impact any type of relationship?

Certainly a patient relationship, too Yeah, absolutely. Now, do you recommend uh, you know, let's say obviously A lot of uh in network insurances now have deductibles Uh, do you recommend uh You know, these practices collect the deductible, the, the, each, each visit, right? Like, so the patient comes in and you do their codes and it adds up to 63 and 40 cents.

Dr. Kevin Christie: Do you collect that at a time or do you, because I go to sometimes like my dermatologist and they don't even collect anything because I have a deductible and network and, but then I get a bill and a statement. How do you recommend chiropractors do that? The best thing to do, from my perspective, is to collect the verification of benefits, the details on the deductible, to have the details of the allowed amounts of those payers, which we often think is harder to get than it really is, uh, but to have that information so that we are able to collect [00:11:00] the deductible amount at the time of service.

Brandy Brimhall: Certainly, if we're not able to do that, if our systems don't allow it, The next best thing to do is collect something from the patient so they're in good habits of knowing that they are paying something at the time of service when they're in the office. And then, of course, get your claims out clean and timely to be able to collect the remainder from them shortly thereafter when those claims come back through.

Dr. Kevin Christie: Yeah, I used to be a network provider. And what we did, we put together a pretty nice Excel spreadsheet. This was 10 years ago. I'm sure there's other softwares now that can do it. And maybe some of the EHRs do it, but we could actually have a different tab for each insurance. And we just had a system where the doctor had to get his or her code codes in.

Before the visit ended, because at a certain point in the visit, you know what you're going to do with that patient. And we would get the codes in, even if the note wasn't done yet. And then the front desk could check what codes it was tabulated on there, put in what the [00:12:00] co insurance was, and it would spit out exactly what that patient was going to owe.

And, and then we would collect that amount and it really reduced those patients statements that you, uh, that you mentioned. Are there, is there any software out there or EHR is doing that now? Like what's the if you wanted to really get an ideal. Uh, of the deductible, sure. So I would say the majority of the EHRs out there now have, they have lots of bells and whistles that they didn't use to have.

Brandy Brimhall: And the majority of them will allow you to input the allowed amounts to help you very quickly calculate whatever the patient co insurance and deductible is. So certainly if you have a software that does that and again, it's, it's the majority of them use that feature. A lot of clinics don't at the same time.

I'm like you, I still use spreadsheets in a lot of ways because it's easier for me to update the allowed amounts to see everything at a glance. So sometimes the old fashioned way works just as well. Yeah, spreadsheets are, are, are amazing. I'm uh, I'm not good at them, but I've started to learn what the capabilities of, and I have a couple of buddies in different [00:13:00] professions that, um, literally run, they work for hedge funds and they, they run multi billion dollar.

Dr. Kevin Christie: Portfolios off of Excel spreadsheets, because I mean, it's, it's insane what a spreadsheet can do. Uh, and so fine, you know, if you're listening to this and you want to do that, maybe find someone that can do it for you, it's not necessarily that complicated, but I'm always, I'd rather you, uh, figure out someone else, delegate it to, to do it, but it's amazing what a spreadsheet, uh, can do for you.

Cause you know, cause one of the things that we had to contend with on that too, was at a certain point that the index, the in network deductible was met and then it was a co insurance. So it's like, okay, the. The codes added up to 63 and 45 cents, but they've met their network deductible. So, and they've got a 20%.

And so we had, we had a whole thing tabulated really nice and it would spit out that they owed, you know, 12 and whatever. And, uh, it was, it was efficient and it really helped us reduce the patient statements. There's still going to be patient statements, but it was nice. Um, on that, on that topic of. On [00:14:00] patient statements, and this isn't going to be for some of our audience that may not be in network with insurances.

We're going to have a little segue here in a minute, uh, to to some of the cash, uh, conversation there. But for those of us for those that are in network with insurances, and they have patient statements often. What's some of the best practices around that of, uh, you know, getting those out in a timely manner, getting people to pay it.

Uh, when do you consider collections? What are your thoughts on sending people to collections? I'd love to hear some of that. Yeah. So the best thing to do follow everything all the way at the top of the stream, because I'm in a, I'm a big believer that aging accounts receivable for insurances and for patients has a lot to do with upstream interferences.

Brandy Brimhall: And so follow everything upstream to be as. It's streamlining as seamless as they're there as you can, without being said, collecting over the counter at the time of service as best as you can, as correctly as you can always the best way to minimize your patient statements next, like you [00:15:00] mentioned, making sure you're sending patient statements in a timely manner.

Those patient accounts that don't make sense to you, that need audited schedule time to go and audit them and not push it off from one month to the next and then have a process because Those patient statements, you know, that 40 or 50 balance after you've sent that statement out. four, five, six times, suddenly you're losing money on that.

And you really do need to have a stopping point. And so what I always recommend clinics do when they arrive at that is we'll first determine what that stopping point is to them. And some clinics it's a year, some at six months, make your decision and be consistent with that. But when you identify those statements, follow it upstream to see how it happened to start with.

So you can do your best to minimize that or reduce that same issue from happening again. Next, what are you going to do next in order to remove that balance or deal with it from the account? Is it sending collection letters? Is it making collection phone calls? Is it going to small claims court? I've done that.

Not the most fun [00:16:00] thing ever, and it's time consuming, but it's an option. And otherwise, selling those accounts is essentially what you're doing to a collection agency, so they can be removed from your books and the responsibility of someone else to collect. That's my preference at this point, making sure that, you know, that your books are clean, because you always, in the clinic, want to work with movable, collectible money.

If it's no longer movable and or easily collectible to you, moving on to somewhere that can work on that. And in my view, that's a collection agency. Perfect. I love it. And then, um, you know, communicating with patients, uh, let's give a couple of scenarios that I think are, that are common. Uh, you know, scenario a is that you've collected that in network, uh, amount, uh, of 60.

Dr. Kevin Christie: And then one of the codes gets denied. So then you, do you technically owe that? Let's say the code was worth 15 bucks. And do you technically owe that 15 bucks back to the patient? Uh, [00:17:00] is there a period of time where you're going to fight the insurance to try to get them to not deny it? What are the, what's the details of that scenario?

Brandy Brimhall: Yeah, so you would have to read the EOB and collect from the patient according to how the claim has processed. So if that 60 copay or whatever the patient responsibility is still shown as the 60, which typically it would be due from the patient, you are still entitled to that man and should have collected it.

With that being said, you're denied procedure code. You'll need to read those EOBs, the remark codes, to determine why that charge was denied. Was it denied because of a missing modifier, because of insufficient diagnosis, because of a payer error, because documentation was requested and you need to send it in, because prior authorization was required, or whatever.

And in that, in any event, Determine why it was denied and that will help you to determine what your next step needs to be as far as collecting on that charge. If you're able to at that point, sometimes you're not because it's, you know, the [00:18:00] coverage has maxed for those types of services. In that case, you know, you adjust the charges and post the EOB according to how the EOB reads.

Other times, you're appealing it, you're submitting records, you're correcting your coding, whatever you need to do in order to get that charge back through and processed. Perfect. And then scenario B would be, uh, let's say it's a straight, there's no deductible straight copay of, uh, you know, 40 bucks, your codes add up to 60 and you know, you're, you're expecting 20 from the insurance.

Dr. Kevin Christie: You got the 40 from the patient. Uh, the insurance denies a code, so that patient actually owes you 20 now, um, which if you fought it and everything and they're just gonna deny it, they owe you the 20. Uh, how do you, like, what are your recommendations on communicating with these patients to, again, not let the insurance company, which they always do, but let them impact the patient doctor relationship there?

Brandy Brimhall: Well, I think it's [00:19:00] important to keep in mind that every EOB or ERA that we get in our office, the patients get a copy of also, so they have the ability to see what was processed, how it was processed, and why the patient balance is what it is understanding. They're not always going to read it, but they do have a tangible resource directly from their insurance company with their name on it, because it was addressed to them.

That explains them the processing detail when I was in the clinics all the time. That was one of the things that we did was we would look at the EOB specifically. Importantly, it's it's very essential for clinics to make sure that they're preparing clean claims, meaning they're processable by the insurance company to the best of their ability, submitting them correctly to the best of their ability and taking whatever next step needs to be taken on denied charges.

if there are denied charges. So we have to read our EOBs, but with all of those things in place correctly, then we're in a good position to have that dialogue with the patient. If they ask, oftentimes we, you know, we send out the patient statement, they may call in and we can show them, [00:20:00] here's a copy of your EOB.

By the way, if you haven't already received a copy, you will be receiving one also to review in detail. And we can always let them know that they are able to contact their insurance company directly if they would like, and if they have specific questions. Perfect. Love it. And I think if you do that with a smile, it'll be, uh, even easier, right?

Dr. Kevin Christie: Um, now what are your recommendations, um, or, and I'm not sure if your company does this or whatever, but you know, you, let's say, let's say a practice, cause I've seen this happen many times, whether it's you have in house billing. Or you outsource to a billing company. What are your recommendations for the owner of the practice to have some kind of oversight to make sure that they're not losing money because, uh, either a billing company or a billing person in house is not doing their job, not fighting it, not understanding it.

Maybe sometimes it's blatant neglect. Uh, and sometimes it's just, you know, it's ignorance. They don't know what, what's happening there. What are your thoughts on oversight and what, what do you [00:21:00] recommend? Yeah, as far as recommending, I'm an advocate of both in house and outsource billing. I love both of them, and I think whatever is best for the practice is ultimately best for the practice, and that's a decision for them to make.

Brandy Brimhall: As far as oversight, with an outsource billing service, I think the best advice I ever would give to someone is to know that you can and should be monitoring those processes. And having communication with that person or that entity, just as you would someone in your office. We monitor by statistics. So you can pull your AR reports, your collection reports, all of the details.

And it doesn't take a long time. It does. It's not, you know, anything overly scientific, but you can compare 1 month to the next, as far as, you Your rejections, your claims that have gone out, your reimbursement, your AR, is it climbing? Is it reducing? All of those types of things, the same processes you would have internally, have with, with an outsource billing service.

And when you meet with them, because they're all different in, in [00:22:00] many ways, make sure that you fully understand where their role starts. And where it stops. And so that the clinic isn't overlooking in the passing of a baton, because that's sometimes actually a lot of times, one of the things that happens is, oh, well, we thought our billing service handled this, but really they don't, some of the common things are, oh, we thought that they would do the verifications for us.

Oh, we thought that they would get our preauthorizations. Oh, we thought they would call the attorneys on all of our PI claims, but they haven't, they're not doing that. So make sure you're clear on what, you know, where you start, where they start and whose responsibility is what. No, it makes, makes sense.

Dr. Kevin Christie: And I, I'm going to, we're going to segue a little bit, but before I do, I just kind of, you know, I, I think there's, there's a trend of a lot of chiropractors that are, uh, you know, going cash, they're, they're not doing the in network thing. Uh, I used, I built my practice in network and then went out of network and, uh, you know, and, and there's a lot of.

There's a lot of pros and cons, but you know, I will [00:23:00] say like, just because my practices is not in network with insurances, doesn't mean I'm against it. And I think there's a lot of variables and I can say with, um, the insights I get from working with a lot of chiropractors, whether we're coaching their practice or they're in our mastermind, some of the biggest practices that I know in the evidence based world are in network with insurances.

So, I mean, it's. Uh, there's definitely some cash practices that are big, not saying that, but the ones that I see that are generating 750 a year, a million, 1. 5 to, uh, they are in network with insurances and, uh, they have built really good systems to, to maintain that. And they are paying themselves handsomely, um, in their personal life.

They're, they're making a professional wage and they've built a team around that to, to, to do it. Now. At the same time, I know a lot of in network doctors that are also struggling. Uh, but [00:24:00] you know, I, I remember listening to a podcast and I, I want to say. I want to say it was Tim Cook, the CEO of Apple, uh, who, who took over, I want to say it was him.

It was definitely a huge company. And uh, you know, I think it was Tim Cook when, when, when, uh, Steve Jobs had passed away. And the thing that Tim Cook was uniquely skilled at, um, was actually logistics. And uh, as you can imagine, a massive company has. Logistical nightmares, uh, that are beyond the scope of what we can imagine.

And this, this particular CEO was just, uh, he was a savant at logistics and he paid a lot of attention to it. And I bring that up because, uh, as, as a chiropractic business owner, if you're going to be. Uh, in network with insurances, uh, you're going to really have to pay attention to the logistics of it.

And you're going to have to know that you can do it. I know practices that have amazing logistics around insurance, and it's [00:25:00] not the nightmare that, uh, one would think it's not easy, but it's, can be worthwhile. And so, um, What are your thoughts on that long little soapbox? I was on with that. Are you, do you see some of the same things that I kind of mentioned there?

Brandy Brimhall: Yeah. And it's payer specific and it's region specific, right? And so a lot of clinics find themselves in network that really aren't advantageous to them, or perhaps they don't have very many patients that have that insurance. And so working with that network may or may not be something that's really beneficial to them.

Yeah. What they need to do first and foremost is get to know their payers because they all have their different rules. They all have their different guidelines. And in order to really communicate with anyone, we need to get to know them a little bit. And the same thing applies for our payers because that helps protect us from vulnerability to and.

audit, recoupment, rejection, all of those types of things when we understand our responsibility in their expectations and how to work within the [00:26:00] parameters of that payer. But but yeah, it's it really is everywhere. One of the clinics that with the credentialing service, one of the calls that I get probably close to every day is I don't know which networks to be in.

So should I just get in everything? And I would say, no, don't, don't do that. What you need to do is do some investigating in your region. What payers are most common and prominent in that region? What employers are, you know, have at the blue cross or, you know, Cigna, Aetna, whatever those networks are and determine from that information what might be a good first choice for you.

Medicare is really common and, you know, most everywhere, the Department of VA, a really good one. So you can get a good grasp on a few of what's likely to be your best payers. And then after that, your patients really start deciding for you because you're going to have patients calling in or coming in saying, Hey, do you take Humana?

Hey, do you take this? Whatever. And as you start to see those types of payers, that helps you to decide, okay, now I need to [00:27:00] investigate this network to determine if it's something that I should and can do, and then move forward with the credentialing enrollment, if that's ultimately your decision. Yeah, no, that makes sense.

Dr. Kevin Christie: And that was like part of what, as you probably know, in Florida, we got the, uh, ash holes took over. And so Blue Cross and Cigna, you know, we, the ash thing and, uh, you know, going back and like, I actually know, I know chiropractors in Florida, really good ones that are still in network with, and they're doing really good with it.

They, uh, they have good communication with patients. And after five visits, when they're not going to let you have any more, they, uh, They tell the patient, they convert a lot of them to cash. And, you know, it's, it's, it's pretty, pretty fascinating how they've been able to do it. And so, um, you know, if I would have, if I were to rewind and go back to 2015, when I started making the decision to go out of network, I don't know if I would have changed my decision, but I know a lot more now about it.

And there's a lot more variables that I think. Uh, clinics need to take into consideration, but let's, um, let's segue a little bit to, to people that are not credentialed with insurances. They're not in [00:28:00] network providers with, with any insurances. Uh, let's exclude the Medicare thing for right now. Do you work with clinics, uh, that are not credentialed with insurances?

Brandy Brimhall: Uh, yeah, a lot of them's coding still matters. We still have, that's a part of the complete and the correct record is coding. making sure that we know our state laws for how we can establish. Some of them do packages and payment plans and things like that. So we have to investigate what they are able to do in their region.

So I help a lot of clinics with with all of that side of their practice. Totally unrelated to the credentialing enrollment and the insurance billing. So like billing compliance, right? Exactly. Yeah, it seems like one of the misconceptions is, and you can correct me if I'm wrong, is those that are, um, those that are cash practices, we'll say, they almost feel like they don't have to abide by billing and coding things.

Dr. Kevin Christie: You see that? All the time. In fact, the most common phrase is, well, I'm under the radar. And so there's, there's no such thing as under the radar. [00:29:00] You have a license, you're seeing patients, you're practicing, you're on the radar. It could be with your state board. You could be requested records and information from an attorney, another provider, even an insurance company.

Brandy Brimhall: In some cases, you know, suppose the patient was in an auto accident and they're trying to determine what was related to the auto accident and what wasn't, you could be requested those records. You're coding is a part of that record. So lots of different ways to show that we're on the radar, whether we're dealing directly with insurance or not.

Dr. Kevin Christie: Yeah. And obviously there's, you know, let's say, uh, you got two clinics that are not credentialed with insurance. They're not in network with insurances. Um, you still could be. Credentialed with insurances, but as an out of network provider. And so you could have a clinic that accepts out of network benefits and does the billing, um, you know, for that patient.

And, and then you could have some that are, are not right. Like there's, uh, we actually are just moving away from that. from it for many years, we have, uh, build out a network benefits for [00:30:00] patients. We, as of, uh, October one of 2024, we've stopped doing that, uh, for the added network insurances, just like so many had high deductibles, this whole thing.

And so, um, we've stopped, uh, doing that. What, what are your. Thoughts on that. What are you seeing with that? What are the things to look out for if you're, you are still out of network with insurances and billing insurances versus just your, you're just not even messing with insurances. Yeah. So a couple of things with out of network, just exactly like you said, if you're not in a network, you are eligible for most of our payers, not, you know, not all of them to bill out of network.

Brandy Brimhall: And as an out of network provider, the first thing that we need to know is we still are responsible for collecting that patient responsibility as it's shown on the remittance, because though we don't have a contract and obligation directly with the insurance company, the patient does, and we can't cause the patient to be in violation of that.

We're putting ourselves at risk too. So that's the first thing. The next is you're right. The deductibles are higher. The patient amount due if it's co [00:31:00] pays co insurances, that tends to be higher with out of network. Some patients like to have a build. Some practices like to bill out of network and it works well for them.

And I think that's fantastic. If that's the case, uh, what you'll definitely want to do upstream in your clinic is make sure your biller, your front desk. Knows the plans and payers that you're out of network with. So they're not miscommunicating with the patients or or collecting inaccurate verifications when those are being done.

Dr. Kevin Christie: I know. Otherwise. Go ahead. Well, yeah. One of the, uh, let's, I don't know if you want to call it tricks or whatever, but you gotta, you've, there's been a lot of chiropractic practices over the years where they are out of network. Um, they'll bill three or four codes to that out of network insurance and collect, you know, uh, 200 for that visit.

Uh, and then, you know, they got the cash patient doesn't have an, and now we're going to collect the 75, like you're going to run into issues there with the dual fee, dual fee [00:32:00] schedule. Uh, there's been a lot of people that will get their 200 and not in the way of the co insurance, right. Uh, you know, what are, what are some of the things you've seen with that part of it?

And it's probably, it's, I'm sure it's still prevalent. You can answer that if it is or not. I know that the deductibles are so high now for out of network It's maybe not as often, but the same thing, even if you build a 200 and whatever dollars out of network and it goes to their out of network deductible, but you do not collect that 200 from that patient.

That's a problem, right? That's a compliance problem for sure. And believe it or not, the payers do find out and they do investigate just about a year and a half ago. I had a clinic that. Contacted me to look for help, you know, to be contacted, connected with an attorney to help them because they have been waiving out of network copays and deductibles and the payers had a particular payer had concluded that was what was taking place and actually had gone directly to the patients to gather information [00:33:00] on what the patients were and were not paying and what ended up happening next.

Brandy Brimhall: Because now we have. You know, we have the enrollment portal and we have the payers have a way to communicate with one another. That really wasn't possible 20 years ago. Right? And so, you know, knows this is what the providers doing now. They've notified Cygnus of the clinic ended up in another audit. With Cigna, not because they were billing improperly, but because they were waiving patient responsibility.

And to the best of my knowledge, that is still going on and has been a very costly situation for that clinic in a lot of different ways. And so just definitely important to keep in mind, it's never worth it. And again, the patients get a copy of that to telling them you're responsible for whatever amount now, they're not necessarily going to come to you and say, oh, geez, I should have paid this much instead of just, you know, instead of nothing in your office.

But it does. Compliance matters and it's. It's never worth the risk for sure. Yeah. It's, it's tricky. Like if you're a chiropractic practice and all you're doing is the manipulation and that's all you build the out of [00:34:00] network. And then let's say there's a deductible and you make that patient pay that amount, it's usually digestible, right?

Dr. Kevin Christie: Like an adjustment for out of network, let's say it's 60. I don't know, like whatever our network would pay. The patient could digest that where you see a lot of the problems is where the. The practice is doing, uh, you know, adjustment, they're, they're doing rehab, they're doing STEM, they're doing, they're doing all these codes and then they're building all that to the insurance.

That's going to like for most of these out of network insurance, like that's going to be about a 200, uh, visit. Uh, and, and you need to, if that goes, if it's deductible, like you need to collect the 200 from the patient, if you're doing it right, when you, when you bill it out to the Cut to the insurance and then you only charge them your cash rate.

Like that's, that's going to be the problem. And that's obviously where if you wanted to get a lot more cleaner as it, as a cash practice is you would just not accept out of network benefits either. You just wouldn't bill. Right. And that [00:35:00] makes sense. Yep, that makes perfect sense. And what you could do instead of billing on behalf of your patients is allow them to self submit.

Brandy Brimhall: They can request a super bill or an invoice from you at any time and self submit. The only thing that you need to keep in mind as the provider is that payer is still going to process that claim information based upon information you provided. So you're still responsible for having correct information.

Claim information, correct coding, and whatnot, because they are processing it based upon information you gave to them, but it makes it cleaner, saves time upstream in the clinic, saves time with follow up, you know, all of the things that take place with billing, and that's one way to go about it if it's a clinic that just can't find themselves any way to comply with the out of network billing rules and collecting properly from the patients.

Dr. Kevin Christie: Yeah, for sure. And then obviously another level of that is where you could, um, you know, contract with a company like Chuso where we've had them on the podcast where, uh, now that we're not going to dive into that, but essentially one thing that I'm pretty sure of, and you can correct [00:36:00] me is that if you do that and, uh, and then that patient, um, signs that Chuso agreement with you and on, on that part, now you're not able to bill to that out of network insurance.

Is that correct? Yep, that's correct. And CHUSA is for things exactly like that. Patients with high deductibles and really almost unreachable benefits, no coverage or limited coverage. And so CHUSA is a fabulous resource to us in clinics and to patients for those exact types of things. And absolutely. Yeah.

And then obviously, um, You know, where it could benefit too is, uh, you know, you're like, you know, state that personal injury pays really well and you bill four codes out to personal injury and you get 200. Um, it's, it's tricky to, to do that. And then the same patient comes in, does four things. And you charge them 65.

That's where it gets, gets tricky. Um, although it's funny and I'd love your thoughts on it or, uh, I won't [00:37:00] mention, but someone posted in a closed Facebook group about a hospital experience and, and he just literally told them the whole time, I just want to pay cash. What's my cat? He had insurance, but he's like, I want to pay cash.

What's my cash rate? And it was crazy because he had a, he had a high network deductible. And if, if he did service a and ran it through his network deductible, it was going to cost like 1, 000. But then they had a cash rate of 400, right? And so even these imaging centers and these hospitals and these big groups, they essentially have dual free schedules.

Is it, am I not wrong in that? No, you're right. And you, they, I do think in some ways they have some latitude that are, is different than what we have in our types of facilities. But at the same time, their rules are, you know, very like the, the no surprises act and the good faith estimate. There are things that clearly.

Brandy Brimhall: Are questionable and how you know what their processes are as far as collections, but to your point, I've done the same thing [00:38:00] numerous times knowing that I'm likely to pay less. Not having insurance or not using my insurance versus using it and then having to pay the deductible because then I'm bound by my contract and they have to collect it.

They don't have the same type of wiggle room as they do if I'm not using any insurance and it's different for them. So, uh, so, yeah, I. I'm right there alongside whoever posted that because I've done it too. It's funny. It's just, uh, yeah, but I'm not here saying just don't worry about it. Have a dual fee schedule, but I just, I find it ironic for sure.

Dr. Kevin Christie: So, uh, this is great. So what are some of the things that you, um, Do you do training for practices on all this type of stuff? Do you, what are some of the services you offer? I know you'd offer credentialing. Actually, let me ask a question on that before we move on. Um, are you finding a lot of insurance panels are not accepting new young doctors in different areas?

Brandy Brimhall: In different regions, there are quite a few closed panels. 1 of the things that we do to help get across the finish line is is simply just to follow up with those [00:39:00] panels because eventually they do open. Many of them are reevaluating their, their rules for enrollment right now. At the same time, for clinics that are chiropractic, and now they're newly integrating, sometimes bringing on a medical doctor or a DO or a nurse practitioner opens up a door for you for enrollment that maybe you didn't realize before with the panel, so there's different things to look at, but we follow up with those panels, but again, to your question, yes, definitely close panels, best thing to do, be persistent and follow up with them, because eventually they'll open, you just, you can't take your fingers off the pulse of it, or you'll find yourself having missed the window.

Dr. Kevin Christie: Yeah. And do you, do you help, uh, practices that are looking to medically integrate with credentialing as well? Or is that different animal? I, we do lots and lots of credentialing for the multi specialty clinics that are already integrated or that are newly integrating, and they're having to shift everything over onto, under a different business group with the, you know, expanded or, or broadened, you know, other specialties.

Brandy Brimhall: So we [00:40:00] do a lot of credentialing for that. Not, not quite half, I would say, but it's, it's a lot, a lot, mostly chiropractic. Yeah. Love it. Great. And then, um, yeah, what are some of the things you're doing for practices? Aside from that, obviously we got credentialing, you're doing some with even medical integration.

Dr. Kevin Christie: I obviously probably do training on billing and coding, but do you help with kind of the logistics of it? Like lay out a map of like, look, this is how you need to implement in your practice to have a proper billing system. Yes, so in addition to the credentialing and enrollment, so we do end to end credentialing and enrollment, lots of help and almost like helpdesk type support.

Brandy Brimhall: So I get a lot of questions of, you know, hey, this denied, what do I need to do next? What's my state law for that? So helpdesk type questions from clinics. All over the place on coding, billing and compliance things, but otherwise clinics that say, hey, you know what, we're, we're struggling in these different areas of our billing, or we're trying to figure out how to build a system.

That's manageable and workable that we can get ahead of and stay ahead of we [00:41:00] schedule. We have actually a lot of recordings on that to help them too, but we schedule private sessions on zoom similar to what you and I are doing right now, other than we're screen sharing and going through their specific steps and processes and helping them to establish that.

while at the same time being support as they begin to execute, you know, here's phase one of what we're implementing for your billing processes. And then we'll come circle back to make sure that's moving along and then, you know, into step two and so forth. So it's very custom for every single clinic.

Dr. Kevin Christie: Awesome. I love it. Well, this has been amazing and a wealth of knowledge, just like when we first met at Jay Greenstein's event there this year in June in DC. Uh, I thank you for your time. Where can our audience reach out to you if they want to find out more information or want to work with you? Yeah, they can reach me at Brandy.

Brandy Brimhall: So it's with a Y so Brandy at rapid credentialing. com and they can also go to the rapid credentialing website and that is rapid credentialing. com and they can contact me. There's a contact us right there that comes straight to me [00:42:00] also. Perfect. This was great. Thank you so much. Absolutely.