Have you found it challenging to decide whether to set up your private practice as self paid or insurance-based? When launching your nutrition business, this is one of the first, and most important decisions to consider. It can be intimidating to commit to one of these financial structures, and many dietitians feel overwhelmed and underprepared when considering credentialing with insurance. Nutrition programs in general lack providing new RDs with the technical know-how to launch a business and properly understand how insurance credentialing, contracting and billing work.

As a private practice dietitian with over 30 years of experience, Muriel Doyle, NC, LD, CDE has seen tremendous success with her insurance-based practice. Throughout her career, she has gained valuable insights into the credentialing and contracting process. This know-how has ultimately allowed her to smartly work with insurance companies, to demand a fair contracting fee and proper reimbursement.

Whether you have an insurance-based or self-pay practice, your clients will appreciate the support and services that can be provided via telehealth. While there are many tools to provide virtual services to your clients, choosing a HIPAA-compliant practice management software is essential in safeguarding your client’s personal health information.

Today Muriel is sharing her insights, to help other dietitians decide whether an insurance-based or self paid private practice is the best model for their business. Follow along as she reviews:

• Initial considerations when deciding between self-pay and insurance
• How to calculate your bottom-line fee prior to contracting with insurance
• Tips to securing and negotiating a fair fee
• Ways to advocate your worth and utilize the right tools to launch and build an insurance-based practice

Insurance versus self-pay: initial considerations for dietitians:

What are some initial considerations for dietitians who are planning to launch a private practice?

First, you have to identify your additional sources of income. The truth is, that starting a private practice will not generate an income on day one. So if you are in a situation where you do have another source of income, you can grow your practice progressively. Give yourself at least 2 years to really say that you’ll be making the equivalent of a full-time employment salary.

Tell us how you think about insurance vs. out of pocket payments structures?

1. Really ask yourself, are you a natural sales-person?

At the moment, I am offering both insurance and self-pay in my practice.

If look back in the past, I never marketed my services. Because I hate to sell myself. Sometimes I feel like I could make more money by doing that. But by being an insurance provider, I find that people will find me through their insurance network.

2. Consider your niche: will self-pay or insurance work best for them?  

As I began to specialize in diabetes, I learned that it was best for my clients for me to take insurance. Through insurance, my clients are covered under preventive care, with no copay and no deductible typically.

3. Evaluate how many private practices are also located nearby

In my area, there are very few private practices that accept insurance. So in the instances where I had an insurance claim denied, I could argue that the insurance company did not meet the guidelines for network adequacy in my state. Insurance companies must list all of the providers in their network on their website because it’s public access. So for me, it was easy to get in-network with insurance companies.

4. Consider how much you want to be paid, and know your worth

It was also easier for me to negotiate what I wanted to get paid. Many times insurance providers sent me contracts that did not list any fees or schedule. But I was not going to sign anything without knowing what my return would be. So I would get the fee schedule, and the pay was so low that it was not worth my time. Because of my position, and being a dietitian who knew my worth, I was able to negotiate. I stood my ground because I learned very early on in my practice not to accept any opportunities that weren’t worth it. It’s rare for me to work for free. I am asked to speak often, to give something back to the community.  Also to ask for something in return, a bargain.

I find it that a lot of nutrition schools do not teach dietitians how to position themselves as experts and to brand themselves in such a way to be successful and worth getting paid for their services. There are too many expectations that we must show up and give a lecture or service for free. This happened to me way too many times.

How do you think the industry is changing relevant to dietitians going into private practice and credentialing with insurance companies?

The challenges for dietitians in private practice today to accept insurance are:

• Learning how to get in-network contracts
• Knowing how to communicate with insurance — you need to find the right person to collaborate with and network with to be your advocate
• Calculating both their “bottom-line fee” to accept from insurance

Pro tip: Calculating your desired contract rate (aka, your bottom-line fee)

It’s important to have a financial model in place for your private practice. The number of clients you see monthly is referred to as your “Monthly Active Clients,” or MACs. The total number of MACs you are willing to see a month, must allow you to cover your expenses and bring you a profit.

Determine what your expenses, profits and goal MACs look like — and this will tell you how much money you need to make per MAC to meet your financial goals. This is your bottom line number! If an insurance contract offers you a fee far below your rate, then you’ll have to negotiate. Do this math before you engage in the insurance contracting process.

Supporting your nutrition practice with the right technology:

What do you think insurance-based dietitians should look for in an EHR platform?

I think it’s important to be set up with a system that automates your private practice processes, and has everything all under the same umbrella. The process of gathering data about the patient, the appointment itself, charting, billing, and the accounting – it’s a four part process. We need to have a system that is super easy to access with a patient to log all of their data in that one specific system.

How does Healthie benefit insurance-based nutrition practices?

• Cost and time savings: I found that I have kept down so many expenses by using Healthie. If I can automate my scheduling and data entry into a platform that does not require me and my clients to fill out multitudes of paperwork. I can E-Fax forms, receive electronic mail and I can digitally submit insurance claims. I have done away with all of the paper in my practice.
• More client sessions, via telehealth: Healthie telehealth has become a huge savior for me in terms of making money because my niche under my interest network is over 100 miles. I can get a patient in my office one time, but I’m not sure if I can get that patient in a second or third time→ may take them half a day from work. By using telehealth, it enables me to get more return visits than ever in my practice. The fact that I can use Healthie not just as an EHR platform, but as a telehealth platform is a lifesaver to make more money than I ever thought I could functionally make.
• Flexibility and convenience: Another thing that I really appreciate from Healthie is that I can be anywhere and use Healthie with just my phone. If I wanted to, I could even do my telehealth appointment while I’m pulled over on the side of the road and see a client via Zoom.
• Automatic appointment reminders. During a discovery call, I will tell clients not to worry about the details. They’ll receive an email and text with the appointment details and my office location. This saves a lot of time, or clients calling me to ask over the phone.

Building a nutrition practice that has long-term success:

Now as an established insurance-based practice, where do most of your client leads come from today?

Most of my clients come from Healthprofs or they find me through their insurance provider, either through the website or by calling their insurance directly.

What do you think builds a private practice business that lasts for 5 to 7 years and is going to build success?

I believe at this point I would like to expand my practice by investing in online programs. I really feel that there is a huge niche that I have not yet explored in having online programs either with:

• A group setting that are private pay clients
• Or having a video-based program that my clients can view on their own time.

*Healthie’s platform makes it super simple to create expanded nutritional care programs. Click here to learn more.

I have already started having private clients that do not have insurance, enrolled in 3 month or 6 month programs. Also I could offer dual programs that cater to clients who are using and self-paying for my services. When clients work with me through insurance, my service is limited to the time I spend with them in session via telehealth or face-to-face. If they join my program, they will also get access to me through texting, food blog, and through additional check-ins in-between appointments. With Healthie, I can do this all under the same platform.

So I have started selling programs to individuals, but in the future, to have more residual income. Besides, tapping into the group session is a smart way. I am hoping Healthie can really help me in setting it up in a way that is successful.

“Healthie has been especially useful for me in regard to these matters when I am trying to take the next big step for me and my business.”

Have you explored hiring another dietitian, or expanding your practice in other ways?

Yes, so right now I have been networking with dietitians who would like to start in private practice that are frightened. I can see them as subcontractors of my practice, but I have to wonder, am I going to invest in training someone who is going to open up their own private practice in 2 years, right next door. That’s the reality.

If I merge into a group practice, I will consider bringing on other dietitians that are in geographically different settings — who want to be insurance-based. But they do not want the hassle of maintaining all the billing and the baggable fees. The advantage is you pool all your resources together such as marketing resources, educational resources, or just brainstorming. The creativity is much bigger with three brains than with one brain.

At this moment, I will make a decision to either invest my time into creating programs as a solo provider or invest into becoming a group practice. Providers can become successful in the long-term with both approaches to expansion.  What I’ve learned as an entrepreneur, you can’t spread yourself too thin, otherwise nothing gets done.

You’ve had a lot of success with becoming an insurance expert, how do you think that dietitians should approach insurance?

The first step is to complete your CAQH profile. Insurance providers will review this information to make sure it’s up to date. The next step is to call the insurance company to ask “who is my network provider?” They will either have the name, email and/or phone number, but there is always a network coordinator. That is the key person to build a rapport with, to stay on top of the credentialing process. They will be able to give you a timeline of how the process will go. It’s important to stay on top of the process — and if I get denied, I will definitely ask why. Always try to argue is needed in my area.

If there is a contract, I will make sure to get a fee schedule. This is almost never included in the contract because insurance wants to change their fee schedule whenever they feel like it. They can not get tied up to a contract, but you can always ask for a fee schedule and compare it with your bottom line.

How often do you go back and evaluate fee schedules and ask for a new raise?

I have a little secret that I want to share with my fellow dietitians. When we look at the fee schedule, one dollar additional per 15 minute unit will transfer into $4,000 if the dietitian has 20 hour patient contact per week for a year. Every dollar that you add per unit bill brings you an additional four grand per year. That’s pretty powerful because you would think that “oh, I’m not going to fight for one dollar.” Insurance may only be willing to give you one dollar — but fight for that dollar!

I don’t think that a dietitian can really have 40 hour patient contact weekly unless she wants to work 60 hours a week. But if you want to do 30 hour patient contact and keep 10 hours a week for paperwork, charting, and so forth. Then that is $6,000 a year when you increase by just $1 per 15 minute increments. It’s a powerful statement, isn’t it? It certainly is a meaningful amount of money.

I stay on top of my fee schedule because after I get my contract, I have a spreadsheet where I periodically double check the reimbursement with my contracted rate. If there is a discrepancy, I will contact my network provider to ask why this was not billed according to my contract.

Do you do billing yourself? What practices help your business run smoothly?

I do! I use Healthie and Office Ally to send my CMS 1500. I also use Office Ally to get my remittance report. Then I log whatever came back by automatic deposit to each client using Healthie. The Healthie reports that I use to make sure that I bill every single client accordingly are:  

• Billing reports
• Appointments reports

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Healthie also has allowed me to have every single patient sign my policy that states that there is a cancellation fee within 48 hours of an appointment or no show. My clients receive automatic reminders for the appointment which I customized to also restate my cancellation policy. Since I have every client’s credit card on file, it removes the guilt I would feel if I would call them and ultimately argue why I have to bill them. I send them a nice email and let them know that I’d be happy to reschedule, but to be mindful of my policy and that I have to charge your credit card. Once in a while, if they need me to delay that by one or two weeks for the sake of keeping my client, I will be happy to do that. However, I was not able to do this prior to using Healthie as an insurance-based provider.

Launching a private practice, whether insurance or self-pay, requires dietitians to have a competitive edge and sense of entrepreneurship. Making the decision of how to financially structure your practice, ultimately depends on many factors, relating to how you envision the long-term vision for your practice, and which type of structure will allow you to best reach your ideal client. Muriel endeavors to empower other dietitians in knowing their worth. For her, an insurance-based practice has been the right choice for a successful and rewarding private practice. To learn more about Muriel, and her story, visit her practice website or connect with her via Instagram and Facebook.