Well, as always, let’s kind of work with what’s going on and changing for us in the realm of coding and billing. And specifically this episode, we’re going to spend some time with American specialty health and Cigna.
Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
And we’re Live. All right,
Greetings everyone. This is Samuel Collins, your coding and billing expert for acupuncture and the American Acupuncture Council. Welcome you to another episode of, to the point by the American acupuncture council. And thank you for spending some time with me. I will always want to give you some updates. What’s changing. What’s going on. What’s new. If you have not, please take a look at the American Acupuncture Council Network site to check our new section. Cause we do update information there. Along with these shows. We also have information on our Facebook page too. If you’ll take a look there. Well, as always, let’s kind of work with what’s going on and changing for us in the realm of coding and billing. And specifically this episode, we’re going to spend some time with American specialty health and Cigna. Cause I know a lot of you have gotten some letters, so let’s go to the slides, everyone.
All right. As always here’s our website, of course, we’ll take a look there. That’s where the new section is, but let’s kind of focus in on what’s been going on or what is going on with Cigna. So let’s take a look at this letter that I’m sure many of you received. Notice. This one is just dated February 26 and it says here Cigna is pleased to announce that they are expanding their acupuncture per provides our customers with access to services effective June 1st. Now let’s read this thoroughly because it says we encourage you to become a participating provider with Ash to support acupuncture services for Cigna customers, benefits plans nationwide beginning June 1st. So let’s start first with notice. It says encourage it. Doesn’t say we require. In addition, it says as a result of this program, this will contract directly with providers for acupuncture services for Cigna benefits.
Now, for those that are familiar with American specialty health or Ash, it is one of the largest plans out there that manages typically chiropractic acupuncture as well as physical therapy. And most people often will give a kind of negative outlook to this company. Now I want to be careful. I’m not saying they’re a bad company, but the one factor that many people focus on is that they simply have a very low reimbursement. They do have some other requirements, but as far as being negative towards it, I’ve heard people say it’s not so much the company. I think they’re fine. It’s just the reimbursement as well. So it says here, we’re going to use that company, which means reimbursements are going to decrease based on this. And it says, provide contract administration, medical necessity, review, and claims processing. Now I will say this. They have a very good plane claims processing portal that can make things easier.
And actually if you use their portal, they actually give you a bonus payment. So that’s pretty good. Don’t get too excited. That bonus payment is literally pennies to a dollar nonetheless. Um, this is what’s occurring now. What’s important. It says we encourage you and then notice here. It says what this means to you. You must be contracted with Ash in order to provide in-network acupuncture services. So what that is saying that if you wish to be in network with Cigna, you must Ash. Now. Sure. Some of you have been through the program with Accu care, maybe a couple others that were handling this. They’ve just simply moved the contract over to Ash. So does that mean they won’t have benefits? No. It just simply means that if you want to have in network benefits, now this is where we really have to decide how well this is going to work.
Now it says here about advantages, continuity of care, access to their Ashlyn, which is their, um, billing portion, no fees to join. That’s all good advantages of a hundred percent, a hundred percent. Peer-to-peer here’s the downside. The downside is they’re often very strict when it comes to medical necessity. Now I’m not saying they’re too strict, but you have to remember, they’re going to look for how well is the care working? What are the changes being made? So it’s something you really want to start to take a look at as to whether or not that’s something you can work with or how many visits you see. Because often after five visits, they’re going to request additional information, which I will say is terribly hard, but it doesn’t mean that’s going to be extra work. And we have to decide whether or not this is going to be a benefit we want.
Well, there’s a second part to the letter and something I want to emphasize here is this. It says for applicable areas, this is not going to include California, Washington, state, Oregon, or Tennessee. So those areas already have contracts with Ash. So you won’t necessarily have to join, but the benefits can be managed there. And it’s not including benefits for North Carolina and Virginia, which they say are upcoming. So what they’re saying is if you want to join, they’re looking for you to join sometime around April 1st. Now that’s when you can begin, do you have to join for you to have these benefits? Is what my concern is. The answer is simply no, the patients will still continue to have the benefits, but what will it pay and how do we decide? So here’s one of the things we do. I do seminars, of course, I’m sure many of you have attended.
And I also have a consulting service that our network that I work with you one-on-one. Well, one of the things you have to do is kind of do what I do with my members. And that is to figure out how worthwhile is it to be a member of this? Let’s start to talk about it this way. I’m going to keep this kind of simplistic for the timeframe we have. But think of it this way. When you join Cigna or Ash, you’re trading something now, what are you trading? You’re trading generally, you’re going to get less money per visit, but more patients. That’s kind of the advantage. If you’re in network, are you going to get considerably more people? So one of the things to consider is how does Cigna patients come to you in the first place? Were they coming to you because you were in network with something or were they simply coming? So in other words, if you are already getting the patients, how has joining going to bring more? In fact, my concern would be, if you join, you simply are going to get less. So the choices, if it can give you much
More volume and will it make up
For the decrease in reimbursement. So let’s talk about the in network and out of network in network means you’re controlled to those fees and you may not collect anything different other than what’s allowed. If you are out of network, they’re going to pay what they allow, but then you can balance bill the patient. Now that balance billing is fine, but how much will the patient take? How much can they afford? Would it be better for them to go to an in-network doctor where they have to pay maybe a $15 copay compared to coming to you where it could be $40? So that’s something to consider. Although I will say this, don’t be afraid to offer your patients good service. People don’t choose acupuncturist because you’re cheap. They choose it because you can help them and make them feel better. And there’s a value to that.
So before we begin in talking about what the fees are of this thing, let’s talk about joining. When you join, you have to wait out what what’s good. What’s bad. So I suggest take a piece of paper, draw a line down the center on one side, please. Yes. On the other side, put no and start looking at the potentials. One thing to start with is, is this plant exclusive? Well, I’ll start with, it’s not, so that’s going to be a no. Why would I join something? That’s non-exclusive unless somehow it could send me many more patients. So I’m going to check a no on that one because it’s not exclusive. The next thing says is the pay reasonable? Well, I’m going to show you in just a moment. Not very now. I’m not going to say it’s horrible, but it’s not very good. So that’s already two there.
The only thing I could think that this would do for you is bring you a lot of new patients. Because if I look under the note, it’s, non-exclusive, it doesn’t pay very much. If they’re already current patients, how does that help? And there’s other requests they have after you do a certain number of visits, probably after five years, I have to do what’s called a treatment authorization. So this is, there’s a lot of downside to this in the sense of the extra work. Not saying it’s too hard, but please go in with your eyes open. I want you to think of the value. Well, let’s talk about what does it cost to treat a patient in your office? By example, let’s say your overhead per month is $4,000 and you see about a hundred patient visits. It’s a month now, again, that’s 25 a week.
That means it costs you $40 just to keep your office open on those number of patients. So by example, under some of these Ash policies, they pay 1550 $5 max per visit. So therefore if you’re getting $50 or $55 max, that means you’re making only 10 or $15 per patient think of how much extra volume. So in other words, if you have only asked patients, you’re going to go broke this one, you have to be a value added patient. And maybe this is where this can make a difference. Can it bring you someone that you have not already seen that will be new to your office? My key factor is going to be, does it really bring that type of value is the trade-off worth it? Well, let’s take a look at what they’ve done in California. Over this past year, American specialty health has worked with blue shield of California.
And what it allows is a car, an acupuncturist to do ENM codes. So exams, acupuncture in some objective therapies. Well, that sounds pretty good. Realize too, this plan doesn’t cover massage or TuiNa. So those services can be built with a patient separately so long as you inform them beforehand. So that sounds good. Except when you see, well, what’s the allowance. Well, even though they say they cover all of these things, the max per day is $55 and it’s inclusive and all visits count towards. So if you have a patient come in and get one service, it’s going to count as a complete visit. There’s no like, Oh, I just did a therapy. It’s still going to count. So here’s their allowance. This is the California. One $30 for exams essentially. And then 20 to 30 for re-exams. Okay. Not bad, but remember that’s still within the max.
So you’ll notice here. The plan says it pays $55 max per visit. Well, isn’t it interesting that the first set is 45 and the second set is 10. So in other words, as soon as you do two sets, you’ve maxed out. Even if you did an exam, do you get paid separately for that? Nope. The max per day is still 55. So therefore there’s really no additional benefit of them to think it’s paying you 55 per visit. Even the therapies you’ll notice are $10. So therefore, even if you did these therapies plus the acupuncture, what are you getting? Pre-visit 55. Now I’m not attempting to sound overly negative. I’m just saying, be aware of what the plan pays. This particular plan with Ash in California pays $55. Now American specialty health does do a medical necessity. And I would say, this is something I believe they’re pretty good at.
They kind of look at the patient. Yeah. As an overall, what do they cover? Things like headaches, hip or knee pain with arthritis or not extremity pain, mechanical irritation, pain, syndromes, back and neck pain. And of course not vomiting. And of course, you know, that Cigna has one of the most prolific diagnosis, allowances of all plans. I don’t foresee that changing the concern is how much, well, how much also relates to, well, how many visits are you going to get out of this? What they do pay attention to is your diagnosis understand less severe diagnosis. Don’t get as many visits, back pain compared to, let’s say a disc injury are very different. They do pay attention to things like this. And when you do your authorization, keep in mind indications in their history, such as it acute or trauma or traumatic chronic. Those make a difference.
A patient with comorbid factors, things that inhibit their recovery should be brought up. But when you do an exam, anything, you do the range of motion, palpation, orthopedic testing. If you do it, neurologic testing, quantify it. Don’t just tell me it’s positive. But also they do pay attention to tongue and pulse. So I’ll give them credit. They do follow some traditional principles. However, at the end of the day, what they’re looking for is can you show that you’re making the patient better? So understand that for $55 after five visits, do you have to do more of this information to get additional visits potentially? And it depends again on severity of diagnosis, they also look at the goals, how are you going to get the patient better? Well, let’s look at what this Cigna proposal is. And I couldn’t put the fee schedule up because it says it’s proprietary, but this is one I received from the, uh, Idaho area.
And, and I should say Midwest. And so you can see here, it’s not much different than what I just showed you. The 33 to 44 exams. The acupuncture they’ll notice here are going to be far cheaper. They are doing $40 for acupuncture. And I want to point out, I put a mistake here. This should be 40, not 45. The additional sets are paid for nothing. They’re just certain inclusive. So if you do one set or 10 sets, you’re going to get the same money. So something to consider when joining these plans, if you are a four set type of provider three set, this is going to be hard to absorb because that means you’re spending 45 minutes with a patient and getting $40 of reimbursement. Now, what if you’re the type of provider that does one set can be efficient. You needle the patient, make sure they’re finding, maybe they rest for a while and you’ll come back kind of a battlefield acupuncture or modern acupuncture style.
Maybe it can work because you can do volume. The difficulty is how much volume can you do? You know, at some point there’s a finite amount of things that an acupuncturist can do. Well, here’s what their fee schedule. Again, same thing for acupuncture and for therapies. So notice $10. So again, what is the maximum per visit? Well, it’s going to be 50 assuming, uh, acupuncture and a therapy. What they haven’t made clear, will they always pay the therapy separately. Now here’s for the region for the East Eastern areas. This is when I got out of DC. You’ll notice about the same prices, prices a little higher than the Midwest, I guess, but then you’ll notice fees are all the same. So what I’m going to suggest when you get into this, notice every therapy. Now the thing that frustrates me with this is how do you justify charging $10 for a hot pack and then $10 for exercise.
When exercise requires one-on-one care, that’s detailed undocumented compared to just lay in a hot pack on someone. How does that seem reasonable? So my bone to pick here is they should be paying providers more. And so I’ve had a lot of providers asking me, Sam, what I joined this? Now, all I can say is I’m going to give my opinion. Each of you have to make a decision on your own, how well this works. If you can do a high volume practice and there are a number of patients that are going to come in, only because they’re in this space, it could be worth it. However, if you are a two or three set provider, right, and you’re getting only $40, that’s going to be hard to swallow, but here’s the point. If you’re out of network, is it going to be the same thing?
Anyway, the difference is you can charge the patient. And what I’d explained to the patient is your plan pays $50. My visit is 80 and what you’re going to get with my visit is a much better level of care. I will be able to spend more time with you and really correct it as opposed to what I call a poke and run doctor, meaning, put the needles in and run out. Now, I’m not saying that in a negative way, there’s places for all types of providers. I could just find this very hard to work with now, how is this going to work? If providers do not join, will they still have benefits? Nothing has been shown from Ash or from Cigna. That patient we’ll lose benefits. If they go to out network providers, I think mostly this is a way to get the PR profession to join where they are going to gain more control.
Now I’m not against the medical necessity side. I think that’s fine. I just think that this reimbursement level is a hard one to sustain a practice. Let’s face it. If all you got were $50 from every patient and you spend a half hour with every patient, that means you make a hundred dollars per hour, assuming everything works efficiently or 800 per day, you can say, Hey look, that’s 4,500 per week. You know, or knowing that 4,500, excuse me. Uh, but those amounts could I, well, there’s 4,500 per week. Could I make that work well? Sure. But that’s, if you’re very efficient within that. So is it terrible? No. Is it really commensurate with what they were already paying? I don’t think so. And so that’s something that as a provider, you’re going to have to look at and decide, is it worth it to me now?
I will tell you, I’ve given you a little thumbnail of information. I tried to get it out there to you to get a little understanding. If you need more or want more, we offer services to do that. Our seminars at the American Acupuncture Council do that, but also we offer a service. That’s called the network. Just take your phone, scan this, come and take a look at the services we offer. Allow me to be part of your team where you can call me, email me, text me, or fax me questions. And we can work this through the, see how this is going to work and how to make sure you can keep your practice viable. I’m not going to be overly negative, but I want to say that obviously this is going to create a much greater level of control with much lower reimbursement. And that’s something I’ll say it’s not a positive for the profession.
So I’ve gotten a lot of feedback from different States and I’m talking to their state organizations where they have surveyed and a large number of providers have indicated they’re not going to join. It’ll be interesting to see if there’s not very many, what will Ash do or Cigna? All the patients will still have access to benefits. So what I’ll say to you is make a good decision for your office, make an informed decision. And the good news is what if you do join or don’t join. Can you always go back and change your mind? Sure. You can always go back and drop out or join. You want to do what’s best for your practice. Remember you are important to your patients and it’s good to be important, but it’s more important to be good. And to give that good service, you want to make sure that you have a viable practice to do it, allow us a chance to help you, but also the American Acupuncture Council is always here for you. Next week’s class is going to be with Poney Chiang. So pay attention to that. Otherwise I’ll say to all of you, best wishes, keep a close eye out and don’t be afraid to take a look and decide to be or not to be if you will. Thanks everyone. I’ll see you next time. This is Sam Collins, your coding and billing expert.