The Road to Private Practice Ownership

Author: Alicia D.D. Spoor, Au.D.

The Academy of Doctors of Audiology (ADA) has partnered with Alicia D.D. Spoor, Au.D. on a new initiative to follow her process of opening a private practice. Dr. Spoor is the Audiologist and President of Designer Audiology, LLC in Highland, Maryland and has agreed to document her process of opening a private practice, from the start. Alicia has recorded short (usually less than 15 minutes) videos and webcasts about her progress and she will also have articles in Audiology Practices about topics related to her experience starting a business. Click here to watch the videos on ADA’s website.
The Real Insurance
“Do you take my insurance?” How many times, as a clinician, has a potential patient called and asked that question? If you’re not sure, just ask the person who answers your phone. It can be a daily question.

Typically, when an audiologist or patient talks about insurance, they are referring to the health insurance policies that a provider participates with at a given location.

The process for determining which companies and policies to accept in my practice wasn’t an easy decision, especially as a new business owner. Before being able to start the process of insurance credentialing, a few details were required.

Required Details
All credentialing applications require a few prerequisites at the very beginning of the process. As a new business, it took me a few extra months to obtain all of this data, which delayed when I could apply for participating with an insurance company.
  • Individual Provider National Provider Identifier (NPI)
    • Every Audiologist has an NPI that identifies them. My first position in Arizona required and submitted for my NPI. This number is specific to me and used for all of my subsequent positions, so I had this information already.
  • Healthcare Provider Organizations (business) National Provider Identifier
    • Each healthcare provider also has a unique business identifier. After filing the state required paperwork to form my audiology business, I was able to start the application for a business NPI. Since I had not yet purchased my location, I did use my home address to move forward.
  • Taxpayer Identification Number (TIN)
    • The TIN is another identifier that is used for tax purposes. This is a federal application, which was very easy to obtain, after I filed my state paperwork for the audiology practice. I completed this step immediately after filing for my business.
  • Practice location (business) address, phone, fax number
    • This step took significantly longer than I had expected… almost a full year longer! Without a practice location and physical address, it was very difficult to apply for insurance, although I could have filed the initial paperwork using my home address and then gone through a change of address after my location was purchased; I did not do this, as I could not see patients without the location anyway.
  • Three professional referrals
    • Many insurance providers require professional references or referrals. Having been involved with professional networks at the state and national level allowed me to find three profession referrals very easily. The insurance applications requested name, address, phone, fax, and emails. Later on, getting hearing aid accounts, I used the same professionals as references, with permissions. The hearing aid manufacturers requested the references’ account numbers.
Since all audiologists are mandatory Medicare providers, I decided to start with the Medicare insurance process. I had heard horror stories about Medicare credentialing, but found it rather easy and straight forward. The Medicare Enrollment Application was online and required all data to be entered correctly before moving to the next section. This forced me to get all of the required details together (e.g. Individual NPI, practice NPI, tax ID) when completing the paperwork. After submitting the online application, my Local Coverage Determination (LCD), Novitas, contacted me because I had mixed my Individual NPI and practice NPI in a section of the application. The contact from Novitas was extremely helpful and after a few phone calls, the paperwork was corrected and my Medicare Provider Transaction Access Number (PTAN) was available less than 30 days from the initial paperwork application. Since the Medicare enrollment was so easy, I thought other insurances would also be as easy.
Deciding on Other Insurances to Accept
In order to determine what insurances I wanted to be enrolled in, I thought back to my prior private practice locations and the reimbursement schedule for hearing testing and what hearing aid benefits were available. As I was hunting for locations, I carefully calculated my hourly rate and was able to use that when comparing insurance companies. I had also attended a few Billing & Coding Bootcamps and knew that finding the insurances used by a high population in my area would also be beneficial. Based on my business model and pricing structure, I knew that I could not accept all insurances just to accept them because the reimbursement rate was too low. The reimbursement of diagnostic testing was extremely important to me. Finally, as I started physician marketing, I asked what their primary insurances were at the physician’s office and then evaluated if having the same insurances would be beneficial for referral purposes.
The Participating Process
After careful consideration, I decided to apply to only one insurance for participation. Since it was only one company, I applied directly to that company using their paperwork. Had I decided on more than one company, I would have completed the application through the Council of Affordable Quality Healthcare (CAQH). CAQH allows for one application to be sent to multiple insurance companies, therefore eliminating the need to repeat the same information by the individual completing the paperwork. After submitting the paperwork, the insurance company’s website stated that the process would take 3-4 months. At two months, I called the credentialing phone number to check on the status. The insurance representative was able to provide confirmation that everything was received and advised me about when to call back. I followed the suggestion and called at 3 months, the earliest the process was supposed to be completed. Nothing was completed at that time. Frustrated, I called every week after that to check the status. After five months, I finally received a general contract by mail.

After reviewing the contract myself, I had about a half page of questions that needed to be answered before I could sign it. However, I also knew that I was not an expert in insurance contracts and hired an advisor to review the contract for me. After the expert reviewed the contract, I had a total of almost five pages of questions.

Following the protocol provided with the initial contract, I faxed my questions back to the insurance company and called to verify the fax was received. It took approximately four attempts by email and phone just to ensure that the paperwork was received.

At this point, I was quite frustrated. The process to get a contract had already take 5 months, longer than the company had initially told me, and five times longer than Medicare!

Then came the difficult portion of the process. The turn-around time to obtain answers to the contract questions was supposed to be a day or two; however, it took three months of weekly, almost daily phone calls to the company to verify that the questions had been received and for additional information to be provided back to me. In fact, at the recommendation of a well-respected colleague, and given no acknowledgement from the insurance company, I reported the insurance company to the state insurance commissioner. Shortly after the complaint was made, I heard back from the insurance company.

The questions I had asked to the insurance company were answered by phone, although I had requested written responses. Short of legal action, I was unable to obtain written responses; however, I took detailed notes and obtained as much information as possible. The insurance company was unable to answer all five pages of my questions, but I shared the answers with my expert reviewer. After a second review of the contract with the answers provided, the expert recommended that I continue with the insurance and sign the contract.

After I signed the contract, it took approximately two weeks to receive a provider number and another week to obtain signed contracts and paper provider manuals.
Future Insurances
After going through the Medicare process and a third-party insurance process, I know that I can apply with other companies to become a participating provider and will do so, if needed. At this time I am focusing on the two insurances that I am participating with, getting the patients seen who waited for the coverage, and marketing to all of my current referring physicians with the new insurance information.

What did I learn through all of this?
  • The time to become a provider outside of Medicare, even if everything is done properly, was more than twice as long as I expected.
  • The patients who are willing to come into the clinic and pay privately, even though I may accept their insurance later on, are golden.
  • Having expert advisors (lawyer, contract reviewer) was critical.
  • Take really, really good notes, including all phone calls (the name, time, date, what number you called from, etc.), faxes, mailed responses, attempts, and more.
Alicia D.D. Spoor, Au.D. is the Audiologist and President of Designer Audiology, LLC, located in Highland, MD. Previously, she was part of the cochlear implant and hearing aid teams at the Mayo Clinic Arizona. Dr. Spoor earned her Doctor of Audiology degree from Gallaudet University in Washington, D.C. and her Bachelor of Arts degree from Michigan State University in Audiology and Speech Sciences. While at Gallaudet University, Dr. Spoor taught at both the undergraduate and graduate levels. She is currently the Treasurer for the Academy of Doctors of Audiology and Legislative Chair of the Maryland Academy of Audiology.