Archive for December, 2010


December 30, 2010

“Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all.”  -Dale Carnegie


In-Network or Out-of-Network Medical Services

December 27, 2010

What does the term In-Network and Out-Of-Network mean?

In-Network = the physician you have elected to see is participating with your insurance carrier & specific plan and has agreed to accept a negotiated contract rate for services rendered.  Typically your out of pocket expense is less with an In-Network Physician.

Out-of-Network = the physician you have elected to see has not elected to be participating with your insurance carrier & specific plan and therefore has not agreed to accept a negotiated contract rate for services rendered.  Typically your out of pocket expense is greater with an Out-of-Network Physician.

Why are some practices In-Network and some Out-of-Network?

Many new and growing practices seek out In-Network insurance carrier affiliations to help build their patient base.  Practices that have been established for some time might choose In-Network participation for security and continuity of care with their current patient base.  Physician’s typically know that patient’s are going to opt to see an In-Network provider because of the financial impact vs just staying with a provider because of the years they have been established there as a patient.  On the other hand, providers might choose an Out-of-Network position to eliminate the hassles of dealing with a particular insurance carrier all together or narrow down the amount of insurance companies they contract with. Regardless of which position the physcian’s office chooses, you as a patient have the option to choose whether to see an In-Network or Out-of-Network Physician.  For the physician, there will be pros and cons with regards to network participation.   This article will address some of the key considerations of In-Network vs Out-of-Network benefits with respect to stability, profitability and patient satisfaction.

Many practices choose to become In-Network providers because of the stability it offers to medical claim billing and the increased potential patient base. In this type of arrangement all medical billing claims tend to be honored more consistently, and reimbursement rates are clearly defined before services are rendered, therefore eliminating much of the medical claim billing guess work. Becoming an In-Network provider also allows practices to tap into the existing carrier patient base and take advantage of indirect advertising through online provider directories and the like. The principle downside with becoming an In-Network provider is that the credentialing process can be time consuming.  With respect to profitability, In-Network agreements typically require pricing concessions for medical claim billing of normal services, therefore reducing the reimbursement rate a practice can expect for services. One of the main arguments in favor of such concessions suggests that, because carriers put a large customer base at your finger tips, practices should be able to offset lower rates with higher volume. While there may be some glimmer of truth to this argument, reduced reimbursements require practices to work much harder to reach the same level of profitability, which is often easier said than done.  Overall patient satisfaction may be higher for In-Network medical claim billing, depending on your market area and the limitations of plan offerings to enrollees. Generally though, patients are familiar with In-Network and Out-of-Network in reference to their co-payments, deductibles and other responsibilities therefore they generally know what to expect. There are typically fewer medical billing surprises for patients when visiting and In-Network provider, thus yielding a higher overall sense of satisfaction.

The Out-of-Network option can be less stable, particularly for new and growing practices, as there they do not have a definable patient base available through a carrier affiliation. Receiving Out-of-Network services can also increase the cost of care to patients who might already be paying several hundred dollars per month for insurance premiums and have only limited coverage for a Out-of-Network services. Thus, unless your practice is in a high patient volume area, or renders a niche service that’s not typically covered by insurance, Out-of-Network medical claim billing can be a negative determining factor for prospective patients since the financial impact is greater. In more competitive markets, the Out-of-Network is an option usually only available to more mature practices with a dedicated patient base and excellent reputation, or can support more in-depth advertising.  With respect to profitability, choosing Out-of-Network medical claim billing is a double edged sword for many providers. On the one hand, there are no concessions necessary in fee schedules so rates can be set as the practice sees fit. On the other hand, carriers will typically reimburse the “usual and customary” rate (at best) with the balance left to the patient. And, carriers are not bound to honor medical billing claims the same way as an In-Network provider, thus, consistency can be intermittent. Nonetheless, if you have a conscientious patient base and a high success rate on patient collections, Out-of-Network medical claim billing can be very profitable.  Patient Satisfaction can be harder to attain when practicing Out-of-Network, as mentioned above, since patients may be required to assume greater cost responsibility. If the practice can tactfully control the associated problems associated with patient collections (particularly delinquent payments, non-payments, etc.), then this may not be an issue. In these instances, shortcomings in patient satisfaction can be mitigated by keeping them fully informed on cost and coverage levels from the outset.

Of course practices do have the freedom to choose which position they take, In-Network or Out-of-Network medical services which means then your claims are either billed In-Network or Out-of-Network. Depending on location, type and service area, the choice can even make or break your business. Also remember that choosing one position or the other is not a total commitment, as some practices might blend their options and elect to become In-Network with some insurances, while remaining Out-of-Network for others. It really depends on the preferences of the practice manager and owner, and past performance of overall medical claim billing. So, when considering your network options, weigh the pros and cons and find the right mix to balance a stable patient base with profitability and high patient satisfaction.

Please feel free to contact us if you have further questions regarding In-Network and Out-of-Network options.


December 23, 2010

“Nothing so conclusively proves a man’s ability to lead others as what he does from day to day to lead himself.”  -Thomas J Watson

Tricare Prime vs Tricare Standard benefits

December 20, 2010

There is a difference between TRICARE Prime and TRICARE Standard benefits for beneficiaries.  The following is information to help you understand both programs:

TRICARE network providers sign a contract with Humana Military to provide care for TRICARE beneficiaries and agree to file claims.

TRICARE Prime enrollees are treated under a health maintenance organization-style model and are assigned to primary care managers (PCMs).  Beneficiaries and their PCMs are responsible for following the referral process when additional health care services are needed.

TRICARE Standard enrollees can choose to see any TRICARE-authorized provider, with no referral necessary.  TRICARE Standard patients who elect to see network providers for their care are using the TRICARE Extra Benefit, which offers lower out-of-pocket costs.  The TRICARE Extra option is similar to a preferred provider organization model.  Humana Military features listings of network providers to beneficiaries through the “Find a Provider” feature at

If you are a network provider and would like more information about the TRICARE Standard and TRICARE Extra program, you may view the TRICARE Provider Handbook or other materials posted to the provider portal at  You may also contact your Humana Military provider relations representative for assistance.

If you are treating TRICARE Standard patients and have questions about issues such as collecting out-of-pocket payments or determining if deductibles have been met, you can use the “Check Eligibility” feature on the secured provider portal.  The feature also includes information about patients’ other health insurance (OHI), if it is on file.  Don’t forget, most OHI will be the primary payer for TRICARE patients, so you will need to bill the OHI first.


December 16, 2010

“In the business world, everyone is paid in two coins: cash and experience. Take the experience first; the cash will come later.”   -Harold S Geneen

Cowtown Netweavers 12.15.2010

December 15, 2010
The inspiration message of the day:
Watch your thoughts; they become words.
Watch your words; they become actions.
Watch your actions; they become habits.
Watch your habits; they become character.
Watch your character; it becomes your destiny.
– Frank Outlaw

Texas Workforce Commission Fall 2010 Publication

December 15, 2010

Have you read the Texas Workforce Commission Fall 2010 publication?  It is now available online.  Click the link here to read or save your copy:

How to Keep Up with Your Accounting Records

December 13, 2010

None of us like paperwork and because of that, receipts get stashed in all kinds of places.  Your pockets, the car, your purse, your briefcase, your day planner, and some even get tossed away.  If you put processes in place, you can avoid many of the headaches at tax time by keeping track of your receipts and other required documents regularly and systematically.  This requires you to be organized and to have a filing system in place that works for you.  If you do this throughout the year, you will save yourself an enormous amount of time.  It is pertinent to have good record-keeping.  Keeping track of various transactions you made during the year will benefit you in more ways than one!

Records help you document the deductions you’ve claimed on your return. You’ll need this documentation should the IRS select your return for examination. Normally, tax records should be kept for three – seven years (see article by IRS here, but some documents – such as records relating to a home purchase or sale, stock transactions, IRA, and business or rental property need to be kept longer.  In most cases, the IRS does not require you to keep records in any special manner. Generally speaking, however, you should keep any and all documents that may have an impact on your federal tax return:

  • Bills
  • Credit card and other receipts
  • Invoices
  • Mileage logs
  • Canceled, imaged, or substitute checks or any other proof of payment
  • Any other records to support deductions or credits you claim on your return

It is never to late to stop and put processes in place, so that you have efficient and effective good record-keeping throughout the year.  This saves you time and effort at tax time when organizing and completing your return and you won’t be stressed out because you have everything you need right when you need it!


December 9, 2010

“It’s not your salary that makes you rich, it’s your spending habits.”  -Charles A Jaffe

Cowtown Netweavers 12.08.2010

December 8, 2010

Today, Mike McCaleb, one of the founders of Cowtown Netweavers ( gave us a talk on Networking Tips.  I wanted to share them with you here.

Networking Tips

1. Have an attitude of giving.  Always giving.

2. People do business with people They Know, They Like, and They Trust.  You need to get to know the people you are networking with.  Find out about them.  Build relationships to represent them and so they can represent you.

3. Leads:  Means you have already called and introduced the person and made it a “warm lead”.  We all have enough cold leads to follow up on.

Health Care Reform Changes effective January 1, 2011

December 6, 2010

As part of the passage of Health Care Reform, two HSA Changes will take effect on January 1, 2011.  Here is a reminder of what to expect:

Beginning January 1, 2011, expenses for over-the-counter (OTC) medications will no longer be eligible for payment or reimbursement from your HSA; however, the law still allows these accounts to provide reimbursement fr OTC medications when you have a doctor’s prescription.  OTC medications that will NOT require a doctor’s prescription to be eligible for purchase with your HSA are:

adhesive bandages, braces and supports, catheters, contact lens supplies and solutions, contraceptives, denture adhesives, diagnostic tests and monitors, elastic bandages, first aid supplies, reading glasses, wheelchairs, walkers, and canes.  You will not need a prescription for insulin and diabetic supplies.

The second provision of the new law is the tax penalty for HSA withdrawals that are not used for qualified medical expenses.  The tax penalty for non-qualified HSA distributions will increase from 10 percent to 20 percent, effective January 1, 2011.


December 2, 2010

“High achievement always takes place in the framework of high expectation.”  -Charles Kettering

Cowtown Netweavers 12.01.2010

December 1, 2010

Thought for the day:  Thoughts become things…choose the good ones!

Each guest was given a copy of Dave Ramsey’s book: Financial Peace Revisted, by me as a gift. I challenge each of you to read a chapter a week. Being debt-free allows you to do unbelievable things for others in your community and around the world. Live Like No One Else so that you can Give Like No One Else!

Happy Safe Trails to you…go be a success!