Leveraging Specialty Practice: Gaining Higher Reimbursement and Accessing Closed Networks

Strategic solutions that create unique treatments and gateways

By Janet Shelly, PT, DPT

In today’s dynamic healthcare environment, where patient needs are diverse and complex, specialty practices within the field of physical therapy have emerged as strategic solutions. These focused practices cater to specific conditions or demographics, offering not only unique treatments but also the potential for enhanced reimbursement rates from insurance providers. Moreover, they serve as gateways into closed networks, allowing physical therapists to tap into markets that might otherwise be restricted.

POWER OF SPECIALIZATION

Specialty practices are the epitome of expertise and concentration. Whether the specialization lies in pediatric care, lymphedema management, or any other distinct area, these practices offer an elevated level of knowledge and precision. Specialized therapists often stay updated with the latest research and innovations in their field, ensuring that patients receive the most current and effective treatments available. For insurance companies, specialty practices represent a targeted approach that can lead to more effective care and, subsequently, improved patient outcomes. The targeted and effective care provided by specialized therapists can lead to long-term cost savings for insurance companies by minimizing the need for extensive treatments, hospitalizations, and emergency room visits. This alignment between specialized care and cost-effectiveness forms the bedrock of negotiation strategies aimed at securing higher reimbursement rates.

NEGOTIATING HIGHER REIMBURSEMENT

Negotiating with insurance companies requires a well-crafted argument that substantiates the value of specialty practices. By showcasing that their specific expertise yields tangible benefits, such as reduced hospitalizations, better patient experiences, and a proactive approach that mitigates complications, specialty practices create a compelling case for increased reimbursement rates. For example, pediatric physical therapy practice can illustrate how early intervention not only fosters healthy development but also reduces the need for more intensive interventions as children age. Another example is lymphedema specialized therapy prevents complications such as infections, cellulitis, and skin breakdown. These complications could otherwise lead to hospitalizations, antibiotic treatments, and additional medical costs. These outcomes resonate with insurance providers who seek to optimize their investments by promoting preventive care.

ACCESSING CLOSED NETWORKS

One of the most formidable challenges in healthcare is accessing closed networks, which are often exclusive partnerships between healthcare providers and insurance companies. Specialty practices hold the key to these networks due to their unique value propositions. Specific healthcare needs may drive high demand for specialized services. Insurance companies recognize this demand and are more inclined to include specialty providers that cater to prevalent health concerns. For example, a specialty pelvic floor physical therapy provider’s focused expertise, ability to meet the unique needs of patients, and potential for cost savings make them an attractive candidate for inclusion in closed insurance networks compared to general physical therapy practices.

BUILDING COLLABORATIVE PARTNERSHIPS

A distinguishing feature of specialty practices is their ability to align seamlessly with insurance companies’ overarching objectives. When negotiating contracts, emphasizing the practice’s collaborative approach can significantly strengthen its position. Highlighting partnerships with other healthcare providers and demonstrating its role in delivering comprehensive patient care reinforces the practice’s value proposition. Insurance plans that offer access to specialized therapy services can attract and retain members seeking high-quality, personalized care for their specific needs.

SPECIALTY REMAINS PIVOTAL

In a healthcare landscape marked by complexity, specialty practices within physical therapy stand as beacons of innovation and adaptability. These practices leverage their expertise and tailored approach to forge a path toward improved reimbursement rates through demonstrated value. Simultaneously, they possess the potential to penetrate exclusive closed networks, presenting opportunities for growth and expansion. As the healthcare realm continues to evolve, the role of specialty practices remains pivotal, shaping a future where patient needs are met with precision and successful negotiation strategies bridge the gap between practitioner and insurance provider.

Janet M. Shelley, PT, DPT is CEO of Medical Billing Center (MBC) and specializes in billing for outpatient therapy. She can be reached at jshelley@4mbc.com.