Outpatient: expanding practice to include private insurance

[BayBoy]

Does anybody have any experience (particularly around ACA) in expanding a city/county funded clinic providing services only to Medicare patients...to now include folks who are privately insured?

Anybody care to share what steps you and/or your business folks have taken to accomplish those goals? Any reading materials you can think of?

While, its not a done deal yet, I have been asked if I would be willing to run a pilot program in our clinic looking at service expansion...and I am pretty worried I am not up to the task. What's worse, I'm at a complete loss for finding the right terms to use in a search engine to find resources that can help.

[mclennan, BSN, RN]

Your first step would be to do some demographic research. Survey your patient (& potential patient) population and find out which private insurances they use the most.

Be aware most private insurers have stringent rules regarding reimbursement. Accreditation and credentialing are a big deal; contact the insurers you'd like to contract with and find out what they require for the best reimbursement rates. Some will want your organization to be FQHC/AAAHC or even Joint Commission accredited. Find out what credentials they require of your medical director. Find out what kind of inspections and equipment minimums they require (for instance, is your crash cart up to snuff? Is anyone on staff ACLS/BLS/PALS certified?

Start at the bottom. Take one thing at a time. And understand it could take months, maybe years! Feel free to PM me of you wanna chat more. I was very involved in a nonprofit ambulatory clinic expansion just like this a few years ago.

[BayBoy]

Thanks mclennan!

I don't see a way to PM (I guess I just realized why I haven't been on AllNurse for a long time, this website can be a bit frustrating).

Its a bit of an odd situation: We run a hospital-based outpatient clinic that currently doesn't accept private insurance. We have a research clinic co-located on a different floor. The hospital and clinic are JC approved. The research program is licensed to operate as a clinic. Since the outpatient clinic is completely impacted by existing patient visits, the pilot is being proposed to be run/evaluated out of the research clinic on a small scale.

So, I'm just a little curious about how to determine what's what... For example, as a licensed research clinic, we actually do not have to have a crash cart. There is a cart for the primary care clinic but that is on a different floor. So, I'm trying to figure out where to get the information I need to be sure our existing research clinic is sufficient. I have searched for state codes but I haven't found anything specific about equipment minimums, etc.

Just curious, what resources did you use to ensure your clinic was in compliance? Any info on how to expand billing practices to include private insurance?