Angie Ates​ – Insurance VS Membership Models: Key Differences, Considerations And Misconceptions​

Introducing Angieu2019s Background 0:00

All right everyone, super excited to introduce Angie. So Angie has over 21 years experience and is a corporate executive, a leadership was the number one district manager with Mimi Maternity and let teams like gap and children's plays and fashion bug and responsible for the $40 million and and her revenue. So I'm really excited to to have her on right now she does something a bit different. She has created herself into an alternate health practitioner. She's, board certified in complementary alternative health, practitioner and launched six successful, clinics and has over 5000 clients, which is a big deal when it comes to automation.

She's the founder and CEO of Academy Epic, an integrated, natural health education platform based on the principles of empowering and equipping others. She's an international speaker, has trained over, 10,000 practitioners worldwide and on stage with, my hero Les Brown, doctor Lee, Cowden, Charlotte Brown, just to name a few. These are big names in the, industry. Her unique ability to shake things up, and ability to take action quickly really provides her with, her helping others achieve truly unprecedented results.

She's been featured in over 200, health training videos and has been hand-selected to customize trainings and companies like, YMCA Northern Nutrition. This bio, she's also highly spiritual as an ordained minister and diplomat of pastoral science. And Fulton is a shaman. She's able to channel her gifts in a much deeper way and bring in cutting edge energy medicine to integrative health practitioners. So the reason I have her on is because she is just a force, when it comes to understanding what it takes to do things big, do things fast and execute on a level that few people have ever executed before.

Now, whether or not you believe or support naturopathy, this is not the point. The point is getting people on to the summit to really talk about and tackle really the business of medicine. So I am super, super, super happy to introduce, and you to the summit. All right. Welcome to the summit. Thanks for being on. Absolutely. I'm thrilled to be here. You know, you have a heck of a resume. And, and it's so interesting because of the amount of stuff that you've been involved in, I'm sure you've seen a lot.

And I'm so happy to talk to you. And ask you about some things that you're familiar with.

Membership Models vs Insurance 2:53

And that's membership models, because, you know, here at Texas Center for Lifestyle Medicine, we don't have a membership model. We have a traditional insurance model, but there's a lot of physicians that are really curious about the membership model, and there's no perfect way to do medicine. It's all very individualized. So let's talk about it. Let me let's for first of all, I just want to start what are some of the most common misconceptions about like membership models or cast models in medicine?

What are they. Most of them are I'm not going to earn any money, right? No one's going to come to me because they all want to use insurance, and no one wants to pay cash. And that is a lie. Those are the biggest ones in all reality. Because, you know, we do have, society that's trained on do you take insurance, but we also have this conscious society community that's waking up going, maybe I don't want to use insurance, and I want a different type of care. And I'm going to do a membership model.

Right. You know, and expanding on that a little bit is I think we all, as, physician entrepreneurs, we all get a little bit of imposter syndrome, like, oh my gosh, who would pay for this? What kind of I'm going to get there's is there some sort of like predictive analytics about about how this is going to go, or is it just like, okay, let's start with my vision model and see what happens. Why? I believe you can set your intentions and actually have a strategy. I help practitioners all the time with an actual strategy.

And you're right, because a lot of folks are thinking, who would pay for me, right? But the reality is, if you are a a professional, a practitioner, that's getting in results, right, your your patients coming to you for a reason and you're going to get an end result, they're going to pay you and they're going to pay you. Well because you just solve their root cause issue. And that's really what the name of the game is. Right. And so, you know, there's I think there's a lot of friction points to, for transitioning some members, some models.

I mean, there's, there's those doctors and I and I just talked to one last week who is currently within the traditional model, pediatrician and wanting to kind of do her own thing because she understands some of the limitations when it comes to, corporate medicine, such as, sometimes patients can't, can't, you know, have to go through a phone tree to get to the right person who goes to a central location. But Essential Location Services 2000 doctors. Right. And so and so, there's, she believes in that to have sort of, you know, hand-holding and stuff like that.

And that's what patients deserve. And that's that's absolutely true. So, and so, you know, for her transitioning from that into the unknown is terrifying, you know, and, and how do we remove some of the frictions in transition? So what are some of the common things that people can experience? You're right on target. I was just at a medical conference where, I had lots of fun at it, I might add. I love working with this sector where they're talking about in medical school. You're not trained entrepreneurship right at all.

And so that is the unknown. So when they're stepping from this, what this perceived as a safety net right into this is all about me. When we can establish a strategy and a framework, some type of structure, then it takes that friction point of I'm going to go broke and not be able to feed my family. So it's really all about creating what is the container that your practice is going to look like? Is it going to be a direct primary care? Is it going to be cash only? Is it going to be membership? Is it going to be a hybrid?

What is it. So the number one friction point of this is unknown. Doesn't have to be unknown. It really can have a container and a pathway, a roadmap as I like to call it, to get you to where you want to go. Absolutely. So, so, I think, if we start with the end result in mind and I think for most doctors, the end result is not necessarily a business model, but the end result is the quality of life. Right? Right. And, and, you know, I think what we have to do is kind of reverse engineer what that quality of life looks like and what the role of you as a doctor is for your patient.

So you kind of threw out some terms there, like direct primary care. What is that exactly? So direct primary care has a couple perceived ideas and then reality. So a lot of folks think that direct primary care is where you're independent and that can be there's also groups of of colleagues that join together to open a clinic. But you're having direct relationship with your patient. That's what you're having. Sometimes you have insurance. Maybe you're going to stay in the PPO environment. I have, a medical doctor up in Michigan that is starting her own, DPC, but she's keeping the PPO insurance because her market is saturated with PPO patients.

So it makes sense. Sometimes, though, you're not doing that. You're just doing a membership where then they get reduced rates on other activities that you're offering other services. Gotcha. And so, so, so the term direct primary care encompasses it could be a full membership cash or it could be a hybrid. Right. So it's not necessarily one or the other. Absolutely. Okay. So so so that's where you sign up for, for DPC. Okay.

Direct Primary Care and Hybrid Practice Structures 8:23

So if, if if you have a cash model that's membership and then you have, a hybrid model that's insurance plus membership, do you then also have a non membership fee for service model as well. Is that a possibility. You can do it that way. I find whenever I'm consulting with any of the practitioners that that's really difficult to delineate and to manage. It gets really messy as I call it. So I believe that if you're going to do insurance, you need to select the best, you know, low hanging fruit insurance that actually pays.

So pediatrics an example you just gave. So this gal focuses on pediatrics. Her PPO in the area has so many well baby checks that she loves to work with the PPO because she actually gets paid right. Where we know that sometimes when you're working with insurance, if you don't know the proper CPT codes and activities and all that, that you're really not getting paid. In fact, you're paying to see the patient. And that's where it gets, again, messy. So I like to work with my practitioners to say, here's your membership.

Let's just say it's $80 a month, and then you give those reduced office visits. So you're you're still getting an office visits. So it's not like a concierge practice where it's 24 seven. You get to see me all the time, but rather it truly is. Here's the membership and here's the boundaries and restraints of the membership, because that's the other friction point. If I do this, then my patient thinks they need access, are going to have access to me 24 seven. And that's not accurate okay. So I guess that's my misconception as well.

Because I assumed a lot of these models have to do with direct access. But you're saying that's not necessarily true. So, so so, I guess then the real question is, okay, if me as a physician, I don't necessarily want my patients for full time, 24 over seven direct access, how is it that I can charge this membership model? What is the value that that I can deliver to my patients that love my patients? No. Hey, this is the value I deliver. Yeah, it's something above what other people deliver. What does that look like?

That looks like they come in for a copay per se for their office visits. $30, where if they were using an insurance at 60 or 75, depending on your insurance. Got it reduced. Labs where we know if you roll up to wherever you're going for your labs, which don't have to necessarily disclose their price and that they're charging, right. So we have that whole base, but we have discounted labs. So you're going to get a TSH for your thyroid for $10, not $410. And then your insurance pays a little bit and you still paid $38.

So that's one of the benefits you're able to offer in a membership. Okay I got transparency. Right. You got it. Yeah. And I'll tell you, you know, me in a, in a in a insurance based practice, transparency can be can be very difficult. And in fact, I think most practices have a hard time delivering that message for transparency in the insurance model. So, but we, we tend to be pretty good at it because we develop a system that's very unlike other practices. But most practices understand if you're a doctor like you take insurance, you understand that sometimes patients can get a bill for a service that was done maybe a year ago.

And part of it is because it's been stuck in the revenue cycle. An agent claims for a year that it's not even your fault, you know. Right. And then and then ultimately they get it EOB and they're like, what is this? This is done last year. You're like, oh, okay, well, maybe you have to write it off or something like that. And that, that is a pain. You know, it absolutely is a pain. There's no transparency beyond that because, you as a data, you don't necessarily know where the heck the, the claim submission is in the revenue cycle as well.

So I do see a value point, for the membership model with transparency. And also, also there's there's cost saving. This does sound like there's cost saving. There's for, for people who really want to take advantage of the system. Right? So definitely when we had our integrative center, in Missouri, when I was a director and also seeing clients and we had our integrative center, we had our nurse practitioner there as well, and we were able to secure a negotiated pricing with Quest Labs so you could go order your labs or get them at the hospital or wherever, or you could get them through us and our membership.

And as I indicated before, that to TSH was $10, not $38. And so you're able to get that type of discounting for your patients as well, which is a huge value site. Absolutely. And I think as insurance becomes more and more complicated, and especially in 2022 and on, that's going to be sort of a sexy thing for both doctors and doctors and patients. Absolutely. And so what about, maybe this this is the third thing that I want to talk about. And maybe it's my misconception as well. It kind of goes back to, the 24 seven sort of on call doctor as a concierge service.

Right. So, so this comes at, at, maybe some ignorance because I'm not familiar with DPC or concierge medicine. Or your or what is exactly the demographics of the type of patients are they're usually more wealthier is more of a mix because in my head, I think they're generally more wealthier. They sort of expect a higher level of, of of attention. So what does that really look like? Well, that is perceived that way, but that is not accurate. So typically on the concierge practice. So I work with a medical doctor out of Utah and I'm the concierge practice.

Hers are geriatrics. So they're spending 3 to 4 to $500 for her concierge

Transparency, Pricing, and Patient Value 14:02

on call medical services as a medical doctor. And they're older, right? They're geriatric is her focus. Now, there are DPC throughout the country that have these families, or you have, organizations like the Christian organizations and the other, health plan groups. Right. The Samaritan and those like that. And so DPC can qualify to be a provider for those already group plans. Okay. Yeah. Usually to answer your question directly, it is all ages. There is no one said age because a lot of folks are opting out of the insurance racket.

And we know it on both sides, good, bad and indifferent and saying, I would rather be able to have a practitioner that aligns with my belief systems, whatever that is, from all the options of medical care out there. Right. And that also is willing to integrate because I believe in lymphatic massage or acupuncture or something like that, and they're willing to work with me and support me on that decision. So I'm willing to pay $200 a month for care for my whole entire family, and only carry a high rider of insurance, which really covers more of the hospital stay or accidents.

Right, versus actual everyday medical care. Right. So yes, you talked about, you know, I think it's health checks, health shared savings plans. You're talking about whether or not you're traditional insurance, but basically, you see a doctor and then you submit on the back end to the shared savings. There's custom ministries and a bunch of other ones as well. So, I know because we actually see these patients in our insurance practice, one of the works very similarly. So that brings me to my next point.

Is, as membership model doctors. There I think there is a way for patients to submit on the back end to the insurance, as long as they got the CPT codes and the itemized list right. Absolutely. You bet. And so it's the best of both worlds. Yes. So, and so whenever there patients are submitting on, on the back end, for the services that's rendered by the, by the physician or the practice, do you know this generally, any kickbacks and insurance companies say, no, we're not going to cover this or anything like that, or is that is that something that could be, improved within a membership model practice?

It can be improved within the membership model practice. It is just about like every other insurance claim depends on who's examining it and what the CPT code is. And other factors. So no big difference that I've experienced. Okay. Great. That that's that's actually good to know because it really allows the patients to really take it into their own hands to and allocate resources and budgeting for their health, which is I think that's how it's supposed to be in the in the very beginning. So I'll tell you this, though, the coronavirus has created something that's weird.

And, and I want to call it medical entitlement. And, and what that really is, is that if you have a coronavirus diagnosis, you 07.1 if you have a Covid diagnosis, then your insurance company has to cover the total health care that's associated with that. That's that's mandated by a government. That's that's very recently. But, what's interesting is that people thought that was a normal thing. Anyways, very few people understand insurance like deductibles, co-pays and stuff like that. And it's not until the, the goods office.

And if a doctor's office actually does pre verifications, they know that out of pocket. But I will say 80% don't do that. And they get billed on the back and get a surprise billing in 2022 that's no longer allow surprise billing is no longer allowed in the United States. Right. And so this this means that doctors have to put in insurance practice set to change their ways. But what it also means is that I think that actually can can create a such a higher value for the membership model as well, because it's not really ever going to be a surprise billing.

Right? Correct. Because there's more accountability for what are we doing here. Right. And a lot of your pieces too are really after that integrative model that root cause no longer appeal for nil, no longer a natural pill for an ill but truly finding root cause when you work with someone like that, you also save a lot of money because you're not doing 85 tests and 15 specialist. Instead you're like, here's my method, here's what we do for assessments and here's where we're going with it. So that helps as well.

Yeah, absolutely. So so let's talk about the integrative health care model, because I have a integrative health care model. We exist strictly within insurance in the traditional route. But but what we do is that we work with other practices, actually, most of the practices that collaborate with us or only take cash or their membership models are also, chiropractors, acupuncture. My mom's, like acupuncture is social and takes cash. Lymphatic massage, cranial sacral therapy. PMF hyperbaric chambers and stuff like that.

So we do we do work with a lot, but we'll get a lot of referred to by those practices. Within the within the membership model, I want to go back to this, specifically the membership model. Is there sort of a range that's like the golden numbered ticket for a monthly fee, or is it just depending on the practice? How does that really work? It really depends on the practice and your location and all honesty.

Medicare, Medicaid, and Regulatory Constraints 19:40

So I have worked with practitioners, professional medical doctors that range anywhere from $50 a month. All the way up to 120 a month for basic membership. I'm not talking concierge because that's a whole that's, you know, that's 24 over seven access. You're charging a whole lot more for that, right? But the basic what we call membership ranges anywhere from that now depending on if you do family pricing too. So some folks are say, okay, $50 for one or it's 75 for a couple and it's $30 a month for every child.

So you have family pricing and then you have individual pricing, because what sometimes happens is that one person may have insurance through their employer, but to add their spouse is, you know, another 500 a month where they can have a DPC for $75 a month. So they just carry a higher deductible for emergencies, but not for everyday care. Okay. Gotcha. That makes sense then. Well, let me ask you this then. One question leads to another. If then they're able to offset cost of the premium they pay for insurance with the DPC membership model, are the services that's done within our primary care or membership model?

Can they go towards the deductible if the patient, submits on the back end? Sometimes. Sometimes not. It depends on what the insurance agreement is and where the practitioner stands with that insurance as well. And I'm not talking Medicare and Medicaid. Medicaid. You know, that's a whole nother beast. Yeah. That's my that's my next question for you. That is that is a whole other beast. So let's let's jump into that for a second. Let's jump into that beast. So for what I understand about Medicare and Medicaid and you know, we take government insurance, and Medicare, Medicaid and Tricare too.

So government insurance, the the the rule is that if you are in network with a government insurance carrier, that's from CMS, if you're in network with Medicare, for example, then you're not supposed to be able to charge for things that Medicare already cover as a cash, right? That's within the contract. Right. And so, so thus far, a monthly membership is also outside of that contract. Is that correct? Correct. And so and so a lot of doctors have to, opt out of Medicare now. I've, I've been in situations where I have two friends that started their membership model practice, but they still did shifts, within like urgent care, but they actually were still within the contract for CMS.

I mean, is it an all or nothing thing or can they just allocate that, shift the contract in that position to CMS and have the membership be outside? You know, each state is different and you have to be very creative. So I'm going to say yes. And then I'm also going to say no. I know they're I know a practitioner, a medical doctor that does not, opted out of Medicare but does call in labs and pharmaceutical prescriptions for her Medicare patients. So it's just a creative working through whatever loophole is needed to be worked through.

Okay. Too complicated to talk to you this summer. That's right. Right. Exactly. That's for sure. And so and so, guys, if you are listening to this and you're kind of straddling, which I know a lot of you are, because I know a lot of you, make sure you consult a lawyer. Make sure you consult somebody. Please consult somebody before you start a new LLC and do your own thing. And then you're in the Medicare contract the same time, I know the state of Texas is very taboo and not really not not, you know, able to do that in the state of Texas.

But you're right, it's a lot of it is state dependent as well, because not not everyone knows that your contract is not with Medicare directly is for it's your contract is for your local Medicare contractor. I make, that's usually, state dependent and or geographic dependent. And each of them have their own specific rules. So there's, there's no blanket statements here. So that's that's absolutely true. I thought this before, and so but and then what the last one I would jump into is, is, is health coaching.

So, you know, there's, on the summit, there's, there's a huge representation of people who are advocacies for health coaching. We got Mayo Clinic on here. Cleveland Clinic uses health coaches. We have Margaret from the National Board of Health and Wellness coaches and well coaches organization. We have, Sandy, who is the head of the, the, from a functional coaching, functional coaching medicine alliance. And then we have also on two other practitioners that have utilized health coaches. So health coaches, recently became a thing in the government.

They got their own CMS taxonomy in April of 2021, which is awesome. And so let's talk about health coaches. How how do we use health coaches and sort of other professionals really in the lifestyle medicine or lifestyle management arena within a practice? So I'll give you an example of how I was recently approached by an ObGyn.

Health Coaching and Integrative Care 24:50

Okay. So she has about a six month waiting list, anywhere from 4 to 6 months. She's a fertility specialist. And so what we created was a 90 day health coaching program. And I how I this is how I describe it. You have a warm up band to the show. Band right. To the cover band. Yeah. And so what's happening is that in this case, we're working with that patient to prepare the body for fertilization. And so in this case, because I trained professionals, we look at not just eating nutrition. Right. What to add, what to take away, what to neutralize.

But we're also looking at nutrient deficiencies. And depending on how long the program is we may even look at pathogens. So we are looking at an EBV virus possibly in the thyroid. Or you're looking at something else, whether through labs or other methods of assessments. So we're preparing that body, maybe through a detox and reset a six month program for that. For this particular Doctor Who, you've got to wait six months anyway. So let's help that patient be ready for whatever's going to happen.

Right. So that's an example. There's other examples because you can actually especially as a even a DPC, you can work within what you're doing, a program that includes lifestyle management and that would be a health coach for 90 days. And and I say health coach loosely, I know, you know, you've got a lot of support from the government for that, what I call preventive care model, which is excellent. Thankfully, we finally do. But at the same time, we want to be really mindful of where the health coach had their training.

I know we were talking about this earlier, that the $12, six hour training on health coaching isn't what we're referring to, correct? Yes, yes. Yeah. There's there's there's new standards. The well, there's not really new standards. There's, there's old standards that are now recognized, as a national standard. And, and even moving from 2022 to 2023, that's going to be far more solidified. And so really, looking forward to that as well. And so, so my last thing is I'm going to ask you, and I asked for most of the people who attended summit.

Well, let me let me tell you this. What do you what do you what have you learned recently that you wish you knew maybe 5 or 6 years ago? Oh, that's a very good question. What have I learned recently? Well, 5 or 6 years ago, I started my training program. That's a really good question. I've learned so much. So I have to pinpoint it to one thing. There's one thing. One most impactful thing. You can think. Yeah. So I'm going to say really probably because of all the, the chaos we currently have as of this recording, constitutional rights and exactly what, you know, taking dominion over your body and making decisions and those choices that we should be able to have over our own body in many aspects, not just current conditions, but in many aspects of even claiming, and owning what we put in our body, mind and spirit.

I mean, I healed myself of multiple autoimmune diseases, and that's the first thing I had to learn is looking in that mirror. I owned it all, and that's been longer than 5 to 6 years, but it really has brought it home again. That preventive care is the way to do it. So anything you can do prevent prevention is going to help the temple last longer you to actually allocating time to care for yourself. You know, a lot of doctors have a hard time doing this, including myself. So you're absolutely right.

So we definitely need to allocate a lot more time for for self-care, for fulfillments, and for understanding that at the end of the day, it's the relationships to ourselves and to each other that truly matter. So I want to thank you for that. That that's really powerful and so welcome. And so, any final advice to the doctors kind of listening to this? And the people who are listening to this are probably trying to decide between different models of practice right now. Any any final piece of advice for them?

I would say that we're in a position in our life right now

Purpose, Profit, and Final Advice 29:08

that purpose, passion and profit. The trilogy is where we need to be going to really live. Our purpose, why we're here. And it's fueled by passion where you're not overwhelmed and, out and but still able to make a profit because we deserve and our professional training to make a profit and to earn a profit. And that is all in alignment with what I call our trilogy. And the final thing I will say is that I love doing the consulting model of helping the practitioners, the professionals transition into a DPC or a hybrid or something that allows them to live their purpose and in their genius.

Right? And to really have that passion, fuel them and ultimately make sustainable profit for themselves and their family. That's my favorite thing to do in life. Great. You got success. Amazing. And we talked about before that we came on you you have you have a gift for audience, correct? Absolutely. So I'd love for you to go to our website at Academy. Epic.com/challenges with the ness. And we have a five day protocol challenge using our four pillar protocol, which is the same approach. We unwrap that in five days, and a four day business challenge, which discusses the three phases of business so you know what to do and what phase you don't need Google Ads and Facebook ads if you're not in the right phase for that.

And really, how to again align your genius with the world to shine, because we are in a moment where we need to shine our geniuses for sure. That is amazing. So thank thank you so much for being on. And go ahead and click on the website. Can you just can can you repeat the URL again. Absolutely. Academy epic.com/challenges with the ness. Excellent. Just go to that URL. Click on one of the challenges. I mean this is really truly invaluable information. And if you guys are actually lost about what model to pick, I mean, we got someone here who kind of knows a thing or two and walk in doctors through it.

And so, so thank you for being on and providing all this excellent value. Absolutely. I'm so grateful to be here. And I hope all the listeners get inspired or a little push from behind to really, again, stand in your genius. It's time and you can always reach me at stuff at Academy. Epic.com. Excellent. Thank you. You're welcome.