Provide What Insurance Does Not Cover!

Urgent Care Nurse

I get asked often “What should my niche be?” and that is a question YOU must figure out. Please read these articles about finding a niche here and here. But another strategy to figure out your niche is to simply provide services that insurance does not cover. For a cash practice to work, you need to provide value to your patient. What is valuable to many patients? Services that insurance will not reimburse for.

Insurance companies are for profit entities. They do not like paying for services if they deem them to be unnecessary. Who determines this? Various committees within the insurance company itself, Medicare, and Medicaid. Essentially, bureaucrats who might be not even hold a healthcare related degree or a professional who has went to the administrative side and has not seen a patient in 10 years. Their bottom line is the priority, not the patient. It is a sad truth, but it is the truth.

Your job as a nurse practitioner entrepreneur is to figure out what insurance does not cover and then provide that service to your patients. If you can figure this out, you will find yourself a cash accepting niche side practice!

Think to yourself, what are interventions that you have prescribed in the past that insurance did not cover? Did you need to go through various pre-authorizations to eventually be declined anyways? These are the types of things you can provide as a cash service.

For example, have you ever ordered an MRI of the lumbar spine that insurance did not want to cover? They first wanted the patient to jump through a bunch of hoops such as going to PT, taking a 3 weeklong course of NSAIDs, etc. before approving the MRI. You are having a PT treat a possible herniated disc off your clinical guess, not the result of the MRI… This saves the insurance company money, but the patient and yourself want that MRI done to see what the issue is and tailor treatment around the underlying etiology.

Guess what? You could just order the MRI at an imaging center and have the patient pay cash for it! I have made a deal with my local imaging center for my cash-paying men’s health patients. I can get an MRI of the lumbar spine WITH the radiologist read for $300…. I can get a brain MRI with contrast and the radiologist read for $350. This is usually cheaper than the deductible the patient would have to pay! It is robbery folks. Many insurance policies are more expensive than just paying out of pocket.

Testosterone replacement is another intervention that is often declined by insurance companies. For example, a patient could have a total testosterone level on two separate occasions be 325 and 315, and have significant hypogonadal symptoms yet the insurance would not pay for testosterone replacement for this patient. It is not “necessary” according to their protocols. According to them, the patient MUST have total testosterone less than 300 on two separate occasions, even though all the symptoms point to low testosterone… This is one of the reasons why men’s health is a great cash practice, insurance does not cover testosterone and erectile dysfunction medications a lot of the time even though it clearly benefits the patients.

Anything cosmetic is completely not covered by insurance. It is not “necessary” for a 45 year old female to look and feel better about herself after a few Botox injections to the face.

It is not “necessary” to provide IV infusion services to a patient who has the flu because they want to feel better faster. But they will cover Tamiflu that ends up costing the same amount of money anyways…

This is a short article because it does not need to be any longer to get this point across. If you are having trouble finding your niche idea or if you simply just want to provide additional services in your already established practice, just ask yourself the question “What does insurance not cover?”

If you have an idea for a service or product, then ask yourself the question “Does insurance cover this?”

The insurance companies have a monopoly on what is and is not allowed… It is a great disservice for everyone in this country. Having a cash practice is the work around. It is good for the patient, and even better for you!

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