How to Avoid Insurance Fraud Red Flags in Your New Functional Medicine Practice
If you are currently "in-network" for a variety of insurance carriers and also seeing functional medicine clients through your own practice "out of network" then you don't want to miss this Legal Quick Hitter.
Communication is key! With most things in the legal and business world, you can save yourself a lot of headaches if you communicate appropriately ahead of time. This especially is true for insurance companies.
It is usually OK to see patients in your functional medicine practice as an out-of-network provider while also seeing patients in network with your current employer. However, you must notify the insurance company that you are doing so. Otherwise, a lot of red flags go up for fraud.
Luckily, it's about the communication, and you can notify the carriers in advance (or, um, now) if you intend to maintain a conventional job (accepting insurance) while your practice grows (cash only). The letter you'll need is called "Notice to Insurance Carrier".
It's a simple step that's easy to execute and will ensure that you are compliant. Learn how to do this quickly in the video below.
Transcript Follows:
Many of you know there are some issues when you have to see Medicare patients from your traditional job, and yet you want to see and open a functional medicine practice and not take Medicare patients, so I've covered that in a previous video. But what many people don't know is that there are also some considerations for private insurance companies as well. Hi, I'm Scott Rattigan, and I'm the founder of Functional Lawyer. This is a legal quick hitter, where we answer your questions in usually three minutes or less. The most common questions we see at FunctionalLawyer.com.
This is one that's come up a couple of times this week, and I wanted to address it. If you're planning on not accepting insurance at your ... let's call it your new job, you should reach out to the insurance companies through which you're reimbursed or through which the company you work for has contracted to be in-network. You want to reach out to them for two reasons. You don't want to make it appear as though you're trying to go around them in conventional care, and you don't want to get red-flagged for that reason as well. And then there are some state regulators that you don't want to run afoul with.
The best way to avoid that is to find the insurance companies that you are contracted with to be in-network, or contact your employer and ask them who you're in network with, and you're going to want to send them a letter. I call it a Notice to Insurance Carrier letter. What that letter will do is just let them know that while you intend to remain in-network at your current job, you're starting a brand new job over here, and it's a different entity altogether. You are practicing a different style of medicine, and it's 100% separate.
It's your understanding that under the master agreement, the master plan that the insurance company has with your employer, that you feel like you are not under that plan in this outside role, and typically you won't be. But you want to send them a letter and just let them know that, “Hey, this is what I'm doing, this is why I'm doing it. And unless I hear from you, I will assume that your non-response is an agreement that that's okay.” Right? And so if you don't hear from them, you can just go ahead and that's the legal notice.
You want to check with the master plan documents and follow the notice requirements, for sure, to the letter. It's very important for legal notice. But otherwise, if you don't hear from them, and you've followed all those notice requirements, then you can breathe a bit of a sigh of relief that you won't have any red flags raised for fraud or abuse. If you have any questions about how to do that, or if you need the template, it's at FunctionalLawyer.com. You can follow us there or subscribe to our videos here on YouTube for more legal quick hitters as we protect you and encourage you and support you in the growth of functional medicine generally. With that, we'll see you in the next video. Have a great day.
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