Dealing With Insurance | S12 Ep60

Choosing between in-network and out-of-network insurance participation can shape your practice, reimbursement, and patients' access to care. Insurance contracting is one of the most complex decisions plastic surgeons face when establishing or managing a practice. From negotiating reimbursement rates to navigating prior authorizations and changing regulations, insurance participation affects financial sustainability, administrative workloads, referral relationships, and patient access. Understanding these considerations can help surgeons evaluate their options and adapt their practice strategies as healthcare policies evolve. Dr. Renee Burke welcomes Joseph Hadeed, MD, Warren Ellsworth, MD, and Keith Blechman, MD, for a discussion of insurance participation from three distinct practice perspectives. Dr. Hadeed shares his experience operating primarily outside commercial insurance networks, Dr. Ellsworth explains the advantages and challenges of participating in insurance networks within a large hospital system, and Dr. Blechman discusses managing a high-volume practice with both in-network and out-of-network arrangements. Together, they examine reimbursement negotiations, the No Surprises Act, prior authorization challenges, and variations in insurance coverage for reconstructive and gender-affirming procedures. Their conversation also highlights the importance of understanding regional insurance markets, maintaining flexibility, and participating in physician advocacy. Topics Discussed Understanding the differences between in-network and out-of-network insurance participation Evaluating how insurance contracts influence patient referrals, surgical volume, and practice revenue Determining whether an in-network, out-of-network, or mixed participation model aligns with practice goals Negotiating reimbursement rates and procedure-specific contractual carve-outs Managing uncertainty in out-of-network reimbursement and patient financial responsibility Understanding the No Surprises Act and its implications for insurance billing and reimbursement Recognizing differences in insurance regulations across states and geographic markets Evaluating the administrative and financial burden of prior authorization requirements Exploring potential approaches to reducing repetitive prior authorization requirements Understanding how insurance coverage for gender-affirming procedures varies among payers and jurisdictions Tracking payer-specific requirements, reimbursement patterns, and authorization decisions Considering the role of professional advocacy in shaping healthcare policy and insurance practices Key Takeaways Evaluate insurance participation within the context of your practice. The decision to participate in an insurance network should reflect your surgical specialties, geographic market, referral sources, patient population, and financial priorities. Understand the trade-offs between reimbursement and patient volume. In-network participation may provide more predictable contracted rates and facilitate patient referrals, while out-of-network arrangements can offer greater flexibility but introduce reimbursement uncertainty and potentially higher patient costs. Explore opportunities to negotiate procedure-specific reimbursement. Contractual carve-outs may establish agreed-upon payment rates for particular procedures, helping practices manage reimbursement expectations when favorable terms can be negotiated. Consider how insurance decisions affect patient access. High deductibles, limited provider networks, and uncertain out-of-network expenses can create financial barriers that prevent patients from receiving otherwise appropriate surgical care. Account for the administrative costs of insurance participation. Prior authorizations, claims processing, appeals, and payer communications require significant staff time and resources that should be considered when evaluating practice operations. Distinguish insurance network status from procedure coverage. A surgeon's participation in an insurance network does not independently determine whether a particular operation is covered. Coverage depends on the patient's plan, applicable policies, and other requirements. Monitor regulatory changes and payer requirements. Insurance rules, reimbursement practices, and prior authorization requirements can evolve. Practices benefit from reviewing current regulations and maintaining organized records of payer-specific processes. Assess financial risks before changing participation models. Surgeons considering a transition from in-network to out-of-network practice should evaluate how changes could affect patient referrals, treatment affordability, revenue predictability, and operating expenses. Maintain flexibility as your practice develops. An insurance strategy that supports a new practice may no longer be appropriate as its reputation, patient population, specialty focus, and market conditions change. Participate in professional advocacy. Engagement with ASPS and state or local medical societies can help surgeons understand policy developments and contribute their perspectives to discussions affecting reimbursement and patient care. Keep patient care at the center of business decisions. Insurance contracting and financial sustainability are important, but clinical quality, appropriate treatment, and patient access should remain central to practice management. Bonus Resources FAIR Health – A healthcare cost information resource mentioned in the discussion for evaluating geographic variations in billed charges and reimbursement benchmarks. Optum – Referenced as a source of healthcare reimbursement data that may help practices evaluate procedure-specific payment information. ASPS Advocacy – Professional advocacy opportunities discussed as a way for plastic surgeons to stay informed about legislation and contribute to healthcare policy discussions. About Enhance Your Practice Enhance Your Practice is the official practice management podcast from the American Society of Plastic Surgeons (ASPS), featuring conversations with leaders in plastic surgery on practice management, leadership, innovation, and professional development. Each episode delivers practical insights to help plastic surgeons build successful practices and thrive throughout their careers. Explore more educational resources from ASPS at plasticsurgery.org.