As an NP in private practice, you’re balancing patient care with operating a business. Unfortunately, the two don’t always align.
All business owners are looking for ways to increase income and boost the bottom line. Upselling and cross-selling are widely used practices to do just that; they increase the value of a sale or service.
While retail and other industries have some restrictions on how they can sell to consumers, healthcare is far more regulated and restrictive.
Employing upsells and cross-sells in healthcare requires careful consideration to stay within ethical and moral guidelines and to operate within the law.
What are Upsells and Cross-Sells?
While we all have been “upsold or cross-sold” at one time or another, we usually don’t think of it in these terms when we experience it.
Upselling refers to recommending a premium version of a product or service, whereas cross-selling refers to recommending a complementary product or service to enhance the primary product or service.
Here are examples from the auto industry that anyone will have experienced.
Upsell: A customer buys a standard car, and the salesperson encourages them to upgrade to a higher trim level with premium features like leather seats, a sunroof, and an advanced sound system.
Cross-Sell: A customer buys a new car and is offered an upsell but declines and then is offered a cross-sell. The cross-sell may be an extended warranty, a maintenance package, or all-weather floor mats.
Often, customers are offered both upsells and cross-sells.
Interestingly, some upsells and cross-sells annoy us, while others are perceived as beneficial; we may even welcome them.
What makes the difference?
The difference can be found in the degree of interest and/or need. The more we’re interested in something or need to solve a problem, the greater our openness to learn more or even try something new.
However, if we’re not interested and don’t need to solve a problem, we will unlikely be persuaded to try something different and even pay for it.
Do Upsells and Cross-Sells exist in healthcare?
Yes! They are used in healthcare more often than you may realize.
Look at these examples…
1. Concierge or VIP Medical Services
Some practices offer priority appointments, extended consultation times, or 24/7 direct access to a provider for an additional fee.
A patient has the option to pay extra for a “concierge medicine” membership to get same-day appointments and direct messaging with the provider.
2. Specialty Products & Supplements
Many healthcare providers sell supplements, skincare products, and other products directly in their offices.
A practice may carry medical-grade supplements offered to patients who express interest in improving their health.
3. “Exclusive” Health Coaching or Wellness Programs
Some healthcare providers upsell lifestyle coaching, nutrition counseling, or weight loss programs.
A weight management clinic may offer a premium membership to access more personalized diet coaching and monthly body scans.
4. Special Lab Services and Panels
Some practices offer specialized lab tests beyond what is medically necessary.
A wellness clinic may offer a food sensitivity test or hormone panel for patients who express interest but don’t show clear medical indications for them.
5. IV Therapy & Vitamin Injections
Practices may offer IV hydration, vitamin drips, or B12 shots as wellness boosters to patients wanting more energy.
After ruling out other causes, a provider may suggest a B12 injection or an “Immunity Boost IV” to a patient who complains about feeling run down.
6. Hormone Optimization & Anti-Aging Treatments
A practice may specialize in hormones, while another may offer it as an upsell to other services provided.
For example, a patient who exhibits mild fatigue and weight gain may be offered a hormone panel and bioidentical hormone therapy as an alternative to standard treatments.
8. Personalized Weight Management & Nutrition Plans
A practice may offer structured programs beyond basic weight loss advice, including meal planning, coaching, or prescription weight loss medications.
A primary care practice offers a “Metabolic Reset Program” that includes monthly body composition scans, nutrition counseling, and guided weight loss medication.
Are Upsells and Cross-Sells Ethical?
This question comes up frequently, particularly in healthcare settings.
Inherently, upsells and cross-sells aren’t immoral or unethical. What may be unethical is the intention behind it or how it is carried out.
Ultimately, utilizing these strategies in your office depends on your intention and comfort level.
The key to ethically implementing these strategies is prioritizing patient benefit and informed consent over pure profit motive.
While this may be challenging, staying within the law and acting ethically is essential.
Patients must understand which services are optional versus which are medically necessary. In some cases, add-ons can be valuable; in others, they may be unnecessary expenses.
Healthcare professionals must ensure that recommendations are explained clearly and are in the patient’s best interest.
Providers must avoid even the appearance of pressuring patients into unnecessary tests, services, or products. Transparency is critical and key to the successful use of these tools.
Are Upsells and Cross-Sells Legal in Healthcare?
While there’s no blanket prohibition against upselling and cross-selling in healthcare, there are laws and rules defining what is and is not legal. They include the following:
Stark Law:
While primarily aimed at physicians, this law prohibits healthcare providers from referring patients to businesses in which they have a financial interest.
For example, if you own a wellness center and refer patients there, you must ensure compliance with self-referral regulations. You must offer patients alternate options and fully disclose any financial interest.
Anti-Kickback Statute (AKS):
You could violate federal anti-kickback laws if you receive financial incentives for referring patients to a specific service or product. This is particularly relevant if you are suggesting third-party services or devices.
State Licensing and Ethics Rules:
Many state nursing boards and medical ethics guidelines have strict rules about commercial influences in patient care. Some explicitly prohibit financial incentives tied to healthcare decisions.
False Claims Act (FCA) and Consumer Protection Laws:
Misrepresenting the necessity or effectiveness of an upsell or cross-sell could lead to legal consequences. Promoting unnecessary services solely for financial gain may be considered fraudulent.
What’s the Risk?
Are you wondering if upsells and cross-sells are risky?
Some may think so. However, the risk should be minimal if used responsibly and following best practices.
Here’s a list of best practices to follow if you’re considering using upsells and cross-sells in your practice:
- Establish medical necessity and/or benefit: Your recommendations should be based on clinical guidelines, not revenue potential. Be clear in your documentation.
- Operate with complete transparency: Disclose any financial interests or partnerships to your patients. If appropriate, suggest alternatives.
- Obtain informed consent: Patients must understand the full scope of what they purchase or the contracts they agree to.
- Check contracts: If you accept third-party reimbursement, check contracts for potential restrictions and limitations regarding upsells and cross-sells.
- Stay compliant: Be sure to obtain legal advice if you’re unsure whether a recommendation or purchase offer could be legally questionable.
In Conclusion…
Upselling and cross-selling can boost the bottom line of your practice. They can be integrated into your practice ethically and legally, as long as patient benefit remains the driving force.
To be clear, sometimes, finding the right balance between patient benefit and the bottom line may be challenging.
When using these strategies, be prepared to navigate a fine line between providing value-added services and avoiding conflicts of interest that could undermine patient trust or lead to legal trouble.
We want to hear from you; tell us what you think… leave your comment below.
By Johanna Hofmann, MBA, MAc., EAMP; regular contributor to the NPBusiness blog and author of “Smart Business Planning for Clinicians.”