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Getting Paid Appropriately by Your Insurance Providers

Throughout your career as a pediatric care practitioner, there are many things you can do to improve your skills, knowledge, and expertise to better serve your patients. Most doctors are familiar with the continuing education they need to ensure that their knowledge is up-to-date, and they are plugged into the latest resources.

However, one area where many pediatric practitioners struggle is financial success while working with insurance. This is an area of expertise that is not taught in medical school, nor is it emphasized on the long road to becoming a fully licensed doctor. As a result, many doctors struggle to get recognized and paid appropriately by public and private insurance providers.

Today, I’ll discuss how pediatricians can get paid for their hard work by re-evaluating and renegotiating their relationships with payers.

Payment, Not Reimbursement

One of the most common mistakes that many pediatric health professionals make is referring to the compensation of their fees as reimbursements rather than payments. As professionals, we deserve to be paid appropriately for our knowledge and expertise. This gives us the resources we need to ensure we can offer the best possible care to all our patients.

After all, you would never walk into a grocery store and tell them that you’ll reimburse them for your groceries in a few weeks. Doctors, like all other professionals, deserve to be paid for their services promptly and appropriately.

In the past, payments were a simpler process. Patients paid their doctors, then submitted the bill to their insurance company for reimbursement. Now, insurance companies operate in between patients and their doctors, adding a layer of complexity and administrative barriers to appropriate payment. This can lead to complex situations where doctors and clinic staff struggle for adequate resources to deliver care.     

Why Some Pediatric Practices Struggle to Achieve Financial Success

The path to financial success can be a hard road, especially when practices are dealing with insurance companies. There are a variety of reasons.

Most doctors do not have a business-oriented or entrepreneurial mindset – their sole focus is on providing excellent medical care to their patients. While this is admirable, the reality is that achieving financial success does require some knowledge or collaborating with a partner who has this expertise.

Another challenge is the ever-changing landscape of health insurance. In the last several years, we as a country have made great strides in ensuring more children are protected by health insurance. However, even these positive changes come with a learning curve. Some practices have up to 40 different insurance contracts and managing them all can be overwhelming. If you don’t have the expertise, make it a priority to educate yourself or add a member to your practice team who has the necessary skill set.

Best Practices for Working with Payers

Are you looking to make a positive change in the way your practice deals with payers? You have the power to make this happen. The easiest way is to make decisions based on data, not emotions.

First, look at fixed and variable costs, then examine how much your practice is getting paid for your most commonly provided services (CPT codes) from each of your payers. After you have both sets of data, compare the two and see who is not even covering your costs to provide care and who is paying appropriately. Using your pediatric EHR to pull up this data and determine how many of your patients are covered by each insurance, helps you to make sound business decisions.

Once you have the information in hand, you have the power to begin to make smart decisions and to negotiate with payers. Not everyone in the practice needs to be adept in this field. However, you need to make sure your practice has one business-minded person at the decision-making table.

At one point in my career, I was forced to walk away from one of my largest payers. They would not negotiate a rate that covered my costs to deliver care. Telling my patients was difficult, but once I communicated the issue to families, they in turn went to the insurer with their frustration, leading to a re-opening of negotiations. Negotiations with payers often start only when you walk away and announce you will be terminating your contract. You have to be prepared to follow-through with a good business plan, but providing care at a loss isn’t sustainable. 

Pediatric success isn’t just about money. However, if you don’t have a margin, your practice mission isn’t sustainable. The more your practice thrives, the better care you’ll be able to offer your patients and their families. You deserve to be paid adequately and your patients want you to be there to serve them for generations to come.

Sue Kressly
kiddrsue@gmail.com


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