A Note from Miguel: Seeing both sides of insurance - Why my practice is hybrid

A while back I said I'd share my honest take on insurance-based care, now that I've seen both sides.

So here it is.

When my practice was cash-pay, a new patient would tell me their story, and I'd order labs that made sense.

Hormones, vitamins, antibodies, whatever the picture called for. We got it all at once, usually for about $150-220, depending on whether it was a male or female panel and what I ordered at the time.

Insurance doesn't work that way.

It pays for a test tied to a medical need, so now I take a stepwise approach.

If A, then B.

If B, then C.

If C, then D.

If D, then you treat.

Meaning, there is a period of time between each test, a new office visit to discuss the results and next steps, multiple trips to the lab, and sometimes delayed treatment.

The comprehensive intake panel I used to order (the 20-30 tests to avoid repeat lab and office visits) is not something insurance will cover.

They don't pay for C and D without making sure A and B aren't the cause.

If I sent the same panel to be paid using insurance, the bill would run roughly $4,000-6,000.

Make that make sense.

Insurance pricing works differently from cash pay. The charges billed to insurance are set well above what insurers actually pay under their contracts. So the same tubes of blood can carry two very different price tags.

So why take insurance at all?

Because for most people, it works.

Visits are covered. Necessary labs and screenings are covered. Costs at the visit are lower, and more people can get the care they need. For patients with high deductible plans, that isn't always true.

The tradeoff is that coverage follows medical necessity guidelines set forth by insurance companies.

That's why I run a hybrid practice: insurance first, with cash-pay options. If you want the full panel, you can still choose it as cash-pay.

For example:

-Specialty labs or functional testing that insurance won't cover

-Hormone therapy that isn't covered

-Testing that isn't considered to be medically necessary, such as genetic testing for an MTHFR mutation

We can talk about options and whether it even makes sense to pay for the test.

Some people really want to know, and this is where cash-pay options come into play.

If a non-covered test is too expensive, we skip it and keep working with what insurance covers.

You decide.

Behind the scenes

Part of the insurance shift happens where you don't see it. Every decision I make is now charted and tied to a diagnosis code, and the majority of my work happens after visits. In my clinical notes and on the admin side.

To lighten that load, I'm moving the practice to a new all-in-one system. It brings scheduling, registration, phone, text, fax, and billing into one place. That means less administrative work for me and a streamlined experience for you.

I’m in the home stretch. Prior charts, records, and labs are being migrated now, and I'm anticipating the rollout on October 25th.

What this means for you:

-I’ll message patients through Spruce once their complete health record becomes available. Please keep an eye on the app and make sure notifications are turned on.

-Once the migration is complete, I'll no longer be active on Spruce and won't receive messages there. The date is still to be determined, and I'll send more reminders before then.

-Your Spruce messages, documents, files, and images aren't going anywhere. You can keep the app as long as you like.

One more thing -

Connect your wearables (FitBit, Whoop, Oura, Garmin, etc.) to Apple Health, and once your portal is live, you can sync your data directly to your record. (LET'S GO! - I'm excited about this one)

You might be wondering - why the dog thumbnail photo?

It’s a photo of my dog, Jax, who just turned 11 over the weekend. Google told me he's about 72 in dog years, and we’re aiming for centenarian status.