Tea Nguyen, DPM (00:54.294)

It's Halloween week, which is my favorite season. I love it more than Thanksgiving and Christmas combined because it's filled with my most favorite childhood memories. From the goblins and the ghouls that dress up to the neighborhoods that set up haunted houses and of course the treats. Sometimes we would get candy, sometimes there were really cool toys. It's also becoming my daughter's favorite experience too, and we just hosted her Halloween bash.

Which was a gathering with some friends over the house, and she really enjoyed being a host. I thought it was really cool to see her do that at age eight. There are two movies that I love watching during this season. One of them is The Nightmare Before Christmas, and the other is Beetlejuice. I love Tim Burton's art. I personally don't like scary movies, so I think there's enough scary things on the news these days that will keep me awake.

It's one of those things where once you see it you can't unsee it. And I never really enjoyed that level of fear. I loved creativeness and things that are endearing and mystical and

Imaginative, but I don't really like to be scared. So this episode got me thinking about some of the scary things that I've experienced as a business owner of an insurance-based practice back in 2018 and stories that friends have shared with me. I wanted to share this with you so that you can get an idea of what's actually scary, what's really happening in private practices that take insurance. And if you're new to business ownership and you're thinking about having a practice with or without insurance or maybe doing some kind of a hybrid. I think it's really important to see this firsthand or to hear this firsthand to know what could happen. Now, this is not to tell you to not do something. I'm not going to do that, but I will share with you experiences that I've had along with the other doctors who have shared with me their stories so that you can prepare yourself.

Tea Nguyen, DPM (02:58.668)

For this next path, whether you choose to take insurance or not. And as you know, I'm a big advocate for simplifying my practice so that I don't work with the middleman. And these are the six scaries that happen if you choose to take insurance. And maybe you are taking insurance right now and you understand this. So stick with me here and see where it takes you next. Starting off with scary story number one, which is not a story. I have to say, these are factual, these are things that actually happen when a practice takes insurance.

What is that? The first is when the service is provided, you have no idea when the money hits the bank. There were times where I performed a surgery and it took a year for the money to hit the bank. Because there was a lot of back and forth. There was charting, there was coding, somebody had to track it. My biller, she was on top of it. And actually when my biller decided to quit, when I was opting out, I didn't need a full-time person anymore. She said, you know what? 

I need a full-time job. This isn't working out for me anymore. She said podiatry is one of the hardest specialties to bill for. So she ended up going back to billing for psychiatry instead. And I was like, yeah, we're all suffering. But we don't have to suffer anymore if we choose to do something else. Now scary story number two. The schedule is full, but you don't know how much longer you can pay your staff. And this was a personal experience for me.

I was going through a really hard time in my first year of private practice, and I never really shared with my staff about the concerns I had around cash flow. But I'll tell you, they experienced a version of me that was truly unpalatable. Everything freaked me out, and I ended up writing about them.

Tea Nguyen, DPM (04:53.738)

And grilling them and just making sure that I was crossing my T's and dotting my I's. So I would check on them and say, Are you calling back new patient inquiries? Are you checking your voice messages? Are you doing enough marketing? All of these things that would rise up inside of me because of the anxiety I had. I didn't know where the money was gonna come from. I just knew I had to get everybody to work at their maximum capacity and then some because I

I wasn't putting a limit on myself, on what I had to do. I just had to do what worked.

And some things was a guessing game, some things consultants told me to do nonetheless. I expected everybody to care about this practice as much as I did. And the reality is they didn't choose this job to be a business owner. They came to support the business owner. So I had to be a better leader for them at the end of the day. Now I'm not proud of those times, and those experiences stayed with me. That fear of not being able to know if I can make payroll the next pay period.

Eventually we went through the pandemic. You know, I opened my practice in 2018, pandemic in 2020. We shut down elective surgery for a little bit, and one had moved on for something more stable. And, you know, I don't blame her at all. These were my lessons to learn as a new business owner, and I'm hoping that you have a chance to learn it without having to go through it yourself, which is why I'm sharing.

Scary story number three. When supplies, rent, and business expenses go up, your insurance rates stay the same. Or worse, it goes down. So what used to be covered is now denied. And now the service was rendered, but the patient says, Well, my insurance should have paid for that. And we go back and forth with this shoulda, coulda, woulda, but the money doesn't hit the bank. And then what? You still have bills to pay. There's still a financial obligation.

Tea Nguyen, DPM (06:55.524)

Is still time wasted. So realize that taking insurance is a unilateral experience. I know there are other circumstances like private equity or group consortiums that can help leverage for better rates, but how much negotiation does that really take for it to become effective? Now in my direct care practice, if my prices have to change, I can do so quickly without having to go through layers of bureaucracy or asking permission or waiting for somebody to say yeah you can do that. I get to choose and I can change those things quite easily and quickly because I need to do things that work for my patients and for my practice.

That's a huge benefit to not working with insurance. Scary story number four wasting time chasing money that's already owed to you. The service was rendered. Money needs to be paid. And I've been told that if you don't collect the money right away, especially if a patient's deductible isn't met, or if you have a new front desk person who collects the wrong amount of copay, I remember looking at an insurance card and it'll say copay for primary care ex dollars and specialists a different amount.

And for a while my staff was collecting the wrong amount. I was being underpaid because they were collecting the wrong amount. And sometimes you don't know what's happening unless you're eagle eyes on everything, but that defeats the point of hiring people if you have to double check everybody's work. But that had happened and I forget how we discovered the underpayment that was happening. I was so traumatized by everything else. It was so hard to keep an eye on every little thing, right? But eventually we realized that

Tea Nguyen, DPM (08:40.304)

the copay collection was not correct. Or when a patient didn't meet their deductible, we should have collected in full and we didn't. So there was all these opportunities of money leaking out. And that's the thing, when you have an insurance-based practice, you need to know all of these things.

But when you have a direct care practice, you need to know none of those things. You just need to know what your services cost and they can pay you on the same day. Oftentimes, if I'm doing a specialty procedure, I request payment in advance before I would even book the case. So I know there are a lot of different ways to protect your finances. And for me, my favorite way to get paid is in advance or on the same day, which is made possible in direct care. And now we have credit cards on file.

Which wasn't a thing back in the day. And so these are measures that I have in place to protect my finances as much as possible. It's not perfect. Sometimes there's a leak here and there, but at least I have better control of what that looks like.

Scary story number five, doing extra work in your personal time after clinic hours and not being able to bill for it, i.e. answering emails, voicemails, other patient portal inboxes. I cannot imagine an attorney doing any of that work for free.

But in medicine, we have normalized that. Now, I am in a position to say I've had enough. And I have a lot more autonomy as to how I spend my time. And that was really hard to do when I was bound by insurance contracts because you cannot bill for those things that is considered part of patient care. But when you're underpaid and you can't keep your doors open.

Tea Nguyen, DPM (10:28.408)

But you also can't balance the difference of your true value and what insurance is paying you. You're kind of stuck in a hard situation of what else can you do to increase cash flow? You can add cash services, you can sell retail products, sure. And definitely consider that if that's available in your specialty. But if you want to simplify your medical practice, be able to deliver the medical care in the way that you were trained to take care of your patients and make sure that you're paid so that you can keep your doors open.

Leaving insurance out of that equation will help you simplify that.

Now does that mean every time I answer an email, a text, or messages from the patient that I'm also charging them? No, I don't nickel and dime people for that time. I don't feel like that's the right choice for me. I would much rather charge them for the consultation and then extra so that it gives me cushion and mental space to take care of any afterthought or questions that might arise thereafter.

Now people don't really take advantage of this access. Some people just need more clarification. And so I make it very clear as to what I can and cannot provide over email. Sometimes it requires an office visit. And sometimes they defer back to their insurance options, which is totally fine. At the end of the day, I'm the advocate for the patient and letting them know what their options are.

So I don't feel like I have to do a whole lot of extra work after clinic hours because I'm able to charge them appropriately so that I can be sustainable in my business and be able to stay open for them to continue care with me. Now the last of the scary stories that exist within insurance based practice, based on personal experiences and others, is clawbacks and audits. A friend shared with me that he had dealt with a Medicare audit.

Tea Nguyen, DPM (12:22.128)

Did everything right, he charted correctly, crossed his T's, dotted his I's, but he had to take out a second mortgage to cover those expenses related to the audit. And even though at the end he wasn't penalized by the government for this audit, all of that time and stress that was spent on this experience made him drop Medicare ultimately. And I know this is not a unique story. I know this happens probably every day.

With doctors having to fight or justify medical necessities when ultimately they are their doctor in the patient-physician relationship. So it's not uncommon that one day something is covered and the next day that exact same thing is not covered anymore. And so the patient is left with a bill. And the government can withdraw money from your account. Are you gonna fight the government? I certainly won't.

But it's the lingering idea of an audit that is always in the back of my mind that

Reminds me, I don't work for patients, I work for insurance companies. And I hated that feeling. Now there are many more scary stories when it comes to contracting with insurance in private practice. But the one that really takes the cake for me is that contracting with insurance takes away time from patience.

I just never imagined taking care of patients meant becoming skilled at navigating those insurance requirements that seem to change on a day-to-day basis. I know many people can, many people are very successful in their insurance based practice, but I was just unwilling to waste my time in learning those things. And so knowing there's another way to practice medicine without insurance actually did keep me in clinical practice. That's why I say everyone deserves to know about direct care, whether it's the patient seeking more.

Tea Nguyen, DPM (14:23.956)

Options outside of their insurance network or doctors who want to design a practice that they love, we should keep talking about it. Plus, there's another market looking for us, and those are employers who are self-funded or self-insured that are looking for doctors like us to provide reasonable rates at a higher value. I talked more about this with Dr. James O'Leary on his YouTube channel. We had a recent conversation together and three specific

Moments stuck with me in our conversation. The first is you are owned by whoever pays you. So if insurance pays you, realize they own you. Realize that you are working for them rather than the patient. The second point was I shared a story about how a lab order was $250 for me with my insurance.

But because I contract directly with the labs as a doctor, if I wrote that lab order myself, it would have been $12. And even as a doctor, I feel like there's always a new door that I'm opening as to, I didn't know that, but now I know it and I can share it. So if doctors like myself and many others don't know the cost of things or don't know there's another option, how can patients possibly know? They can't, right? So we need to help advocate for them.

So that they know there's better alternatives out there. And a third point that I made in our conversation was the biggest mistake doctors make when they go into a direct care practice.

That they think their medical degree will bring in patients. That they think being nice and sweet and kind and thoughtful and intelligent is going to be enough to bring patients in the door to make them want to work with you and pay out of pocket. And that's only half of the truth. The other half

Tea Nguyen, DPM (16:23.582)

is having business skills, which is something that nobody ever taught us in our medical training. So yes, you need your medical degree, and yes, you can learn the business skills to invite those people into your practice where they are happy and willing to pay out of pocket for your medical care.

The full conversation is linked in the show notes. Please continue to support our colleagues in getting the word out there about the benefits of direct specialty care. You have the power to share this information so that more people know that direct care is a viable option for specialists who are ready to leave insurance. I'm curious to know, do you have a specific scary experience with your insurance practice? I'd love to hear it. Let's connect on LinkedIn or Instagram. I'm not really on Facebook anymore, but if you're on my mailing list, just hit the reply button. I'd love to hear from you and I read every note. Until next week, take care for now.