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No Surprise Billing in the Acupuncture Setting


So today’s program is going to hit a chord. I think for many of you, because you’ve probably heard a lot about this and you aren’t yet. Does it apply to me? Does it not apply? Does it really matter? And of course it does. But we have to make sure that we don’t create something where we’re creating too much emphasis on one thing and not understanding the big picture.

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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.

Hi everyone. This is Sam Collins, your coding and billing expert for acupuncture, the American Acupuncture Council Network and the American Acupuncture Council malpractice carrier. With another episode of, to the point to make sure your practice continues to grow and thrive and understand what’s changing and updating to make sure you’re always having the best success that you can have.

So today’s program is going to hit a chord. I think for many of you, because you’ve probably heard a lot about this and you aren’t yet. Does it apply to me? Does it not apply? Does it really matter? And of course it does. But we have to make sure that we don’t create something where we’re creating too much emphasis on one thing and not understanding the big picture.

And that of course is the no surprises act. So please let’s go to the slides. Everyone. Let’s take a look at what’s going on with this no surprises act. This has actually been something that’s been out for a while. It just became implemented January 1st. And really what it’s intended to do is to protect patients from an unexpected or undisclosed medical bills.

And I want you to think of the big picture. Think of how many times you’ve heard of this. That’s gone to a hospital when they’re there. Maybe they get a surgery and it turns out the anesthesiologist is not in their network. And lo and behold, now they get this bill out of network for thousands of dollars.

They had no idea. That’s really the onus behind this. So again, I always report to you to take a look. There’s my name, there’s our website and my email to make sure you’ve got all the right information. But here’s what I want bust. The hyperbole, you’ve all been exposed to this. And if you’re using Dr.

Google, you’ve probably been exposed to it. People love to put out stuff and not really understand it. Think of all the different things you’ve heard about vaccines that turned out to not be true as far as mandate. The other thing about this is the same thing with the no surprises act. And I always say be careful, gave away the exaggerations of a hyperbole.

And I would say use something that’s called Aquaman’s re. If you’ve never heard of that concept that often says that there are very complex questions and often the best answer is the simplest. And I’ll say, this is no different. So starting January 1st, this no surprises act was designed to protect individuals from very high out of network bills or just high bills without them being aware of it.

That’s all this is about. So you have to think from an acupuncture standpoint, aren’t you probably doing all this. Chances are you are cause aren’t you already doing some type of financial agreement with your patient. So this is essentially the design, these big bills. The law requires that providers give a good faith estimate.

You’ll hear this term. It’s an estimate. I probably don’t think in some cases you’re going to be able to give an exact, but at least a range, by the way, that range could be within $400. So you can imagine how many of you have a visit? That’s 400. So I don’t think it’s going to really fall outside of that, but I want to think of just what’s better for us is to make sure patients understand what’s going on.

Obviously, there’s going to be two things that are a barrier or a patient coming for care. Number one, they don’t know about what you do or afraid of it. Unknowing. Isn’t going to work, but number two is cost. And so the better we are at aligning what our costs are in the patient, understand that the better off we’re going to be.

So if you think of it, aren’t you already doing a financial agreement, making the patients aware of what your charges are and what their out of network or excuse me, out of pocket costs might be whether you’re in or out of network. So what I’ll say to most of you. Chances are you are already doing all the things you need to do for the no surprises act albeit maybe a little bit differently, but for the most part already accomplishing that.

So who has to do this? The, who is people with health insurance, many of your patients, whether they use insurance or not, or pay cash, we have to make them aware. So if they’re using your health insurance for. Or not, it’s simply making sure a patient’s aware of what are the expectations of costs. And this is where things can get a little tricky because if you’re in network or out of network, that’s certainly can make a big difference.

So here’s what I, to suspect that you’re doing at our hope you’re doing how about some simple language in a financial agreement that something like. Many insurance policies do cover acupuncture care, but this office makes no representation that yours does. We’re never promising think of a medical office.

They never tell you, we guarantee your insurance is going to cover, or that we take it. They’re saying that we will take some or offer it. And it says here insurance policies may vary greatly in terms of deductible and percentage of coverage. You’ve seen. Yeah, the plan says it pays 80%, but of course, 80% of what, not necessarily what you’ve built.

So here’s what we tell them because of the variance from one insurance policy to another, we require that you, the patient be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. And we’ll do our best to verify your insurance and bill in a timely manner.

But ultimately let’s always remember who is the contract, really with an insurance it’s between the patient. And the insurance company. Not necessarily the doctor and Lusher and network. So you want to be very clear if you’re out of network, we want to be clear as to what your charges are because the insurance is going to pay.

Some of it. Patient pays the rest. When you’re in network may be a little easier, but obviously you’re getting less money. What if you have a $10 copay? That would be pretty strictly. So we have to do it for the patients, give them information, but who else? Us as providers, we give that information and we have to make sure we understand our differences.

When we are in network, it’s mostly a fixed co-pay and we’re going to write off by example, let’s say you’re billing an American specialty health plan, and maybe the patient has a $20 deductible, or excuse me, a $20 copay. That’s automatically what they’re going to pay. Other stuff is written off. You remember, regardless of what you do, right?

You could do lots of services, but they’re going to include just that fixed per diem price. So it’s very, in fact, straightforward. This is what the patient will pay. This is what we get now, conversely, where it gets a little bit more complicated though, is what about out of network? And this is what I want to warn you is that so many offices do this improperly.

You’re probably setting yourself up for something that they would consider anti-kickback or a kickback as well as a false claim when you’re out of network and building insured. The patient has to pay what the insurance didn’t pay. We often use the term co-insurance because co-pay, we generally mean a fixed amount.

Co-insurance we mean, what is leftover? So here there’s no contractual write-off so let’s take an example. We build an in-network plan, a hundred dollars, but because we’re in network, that patient has a $10 copay and the insurance pays $40. So we collect 50 with $50 being written off because we have a contract with that.

Now let’s take another patient. We’re out of network. We build the same $100. The plan let’s say still pays $40. Great. It pays 40, but now because we build a hundred we’re to collect $60 and I know many of you go no, I don’t collect that. I’ll write it off. There’s the kickback you’re giving the patient again.

Of $60. They didn’t pay. Cause why are they not paying what others have to pay? So in other words, you can’t have it just because your insurance is not as good. You pay less unless you’re in network. So if no contractual, write-offs kind of what you, bill is what you have to collect. So be careful of that being a kickback, like by example, if you just told a patient, oh, you have a deductible, no big deal.

I won’t collect it. That’s a gift. And we can’t give gifts for a patient for, to become a patient with us. So I will always come back to say, if you’re willing to build it, you have to be willing to collect it. So be careful of setting your fees off of your best paying insurance or your worse, because if you have one insurance paying that much, what about the patients that doesn’t, they have to pay the difference, which means for many of you, if you’re doing that, you might as well join and be in that.

Because you’re writing it off anyway, you might as well do it legal. So here’s the difference. We have to make the patients aware of that. So as the provider, we have to do to make sure they’re aware of what those amounts are. Don’t overcomplicate it, but it’s really just the out of network of the patient.

Now, if you’re in network fairly simple, because you just telling them what that price is, and I’ll give you some examples of what these forms might look like. But what I want you to keep in mind is what you’re charging. You have to be able to make sure patients understand those. Maybe what their insurance might pay at least a portion, and then they’re going to pay the balance.

So if I’m billing $400 per visit, I can’t guarantee what the insurance is going to cover. Do I have to make the patient aware they could be liable for $400? They couldn’t be. So again, be careful don’t set your fees off of your highest. Now who else has to deal with this? It’s not just us or the patient, but the insurance company, the payer, and here’s some really good rules that they have to follow that I’m sure some of you have run into problems with.

They have to verify who’s in and out of network. How many times have you seen someone coming to your office to say, oh, I found your name on my network and it’s something you dropped out of months ago or years ago. So now they have a duty to make sure that list is updated every 90 days. And it has to be updated within two days of notice, which means many of you are going to get an additional request from insurance companies very regularly, probably every three months to make sure you’re still willing to be in network because those lists have to be up to date because if the insurance company improperly puts your name on that list and that patient comes in the patient, won’t be liable to you.

But, That insurance company, because your name was on the list. They misinformed the patient. So it puts a lot back onto that insurance company, which I liked because how often are we left on the side when we’ve dropped out or we’re not part of it. And yet they try to say that we are, it also emphasizes this, that insurance companies have to be more transparent as the amount that they’re going to allow her pay.

How frustrating is it? You bill 75, 1 insurance pays 41 pays 30, maybe one pays the full 75. How do we know that? Partly once you, bill, you can obviously keep a log of what different plans pay, but otherwise the first time [00:10:00] out, how would you know? And so this is where you have to warn the patient, that I cannot guarantee what your insurance is going to cover.

You can certainly estimate it, but you’re not guaranteed. So potentially they can, oh, the entire amount. Now insurance companies should be more transparent to give that information. There should be more access to online portals or information about what they allow. I would even in fact, have the patient call and say, what do you allow for acupuncture blue cross blue shield of Illinois through their Availity platform.

And I’m sure others are going to follow the same thing. There’s a tool available. If you’re a network you can plug in your codes and your. They’ll tell you what they allow that way. There’s going to be no guessing. What’s there now. Bear in mind. If you go back to ELBs, you’ve received, it’s probably easy to figure out what’s been paid, but it’d be nice to really more real world information about what they’re allowing get rid of that mystery.

Why is there always a mystery of what they’re willing to do all. For the payers, there’s going to be a way to dispute. So it says here out of network physicians, [00:11:00] clinicians, and facilities, wherever process, available to challenge inadequate out of network payment. So you ever seen this ridiculousness, you are billing a fee that everyone pays you and all of a sudden this insurance says, oh no, the usual customary for your.

Is 50% below that. Wait a minute. What means that they can do that? If they’re charging, what is fair and reasonable now, again, if you’re in network, they can make that provision, but out of network, no. So there’s going to be an independent dispute resolution and independent body that will oversee that.

And I think is going to make this a little bit more reasonable that these companies can’t come out and just say this is what we’re going to pay. Take it over. Unless you’re a network. So it gives a little more power for us and the patients to push back on some of these ridiculous low fees that they allow.

So in summary, here’s what I want you to do. Establish a fair and reasonable fees schedule. I did a program about, oh, just right before December, about how to use RV use, but I’m going to. Hire me as an expert, we have a service called the network at the American acupuncture council network, where I [00:12:00] help you just with that to make sure your fees are in line out guarantee.

Most of you have 50% of your codes that are probably not correct. So let’s establish a fair and. Clarify who you are or not in network with them. When people come in, you can be upfront with them. I don’t belong to Aetna, but I do belong to blue cross. Maybe in addition, disclose your fees. Now, what you can do is you can put a big list of all your codes and fees, but that doesn’t really help because that’s not what the patient is getting.

So you want to do something that identifies with this patient is receiving so they know what they’re paying. Can you imagine if you just went to a hospital? And they had a big charge list of everything they might do. How would you figure out what you’re getting done? So you want to be more specific? So the patient has a good choice to know.

Oh, okay, great. I’m going to get this care because I know I can afford it or I will pay for it or here’s what I would rather do. I would rather not treat someone and not get paid, then treat them and not get them. You get my point. That’s happened to all of us at some time, be clear with their [00:13:00] out-of-pockets eight or out of network with a financial understanding or agreement that way.

No, one’s had a mystery and you’re thinking we’ll see them. This no surprise act is what I’ve already done is try to give a patient information about what their costs are. That’s exactly what. What I will say, avoid the hyperbole of when people get all excited, you gotta do new forms. You gotta do this and that.

No, don’t post it on your website. You don’t know what they’re coming in for. Wait until they’re there and use something like this. So you notice this is a simple form that just goes into the same thing. I said, many insurance policies do cover acupuncture, but take a look at where the blue arrow is. It says our services may not be covered by insurance.

Our office and providers are not in network with any insurance. And do not accept insurance assignments, meaning we’re expecting you to pay up bill your own insurance, or you wait for the check. You will be billed the cost for your care and will be responsible for that amount and any difference that the insurance pays great, but that’s not going to be on.

We then indicated in red that the patient says, I [00:14:00] understand, and I will have the financial responsibility applicable to healthcare services provided by an out of network provider. Remember, don’t make them think that you’re in network when you’re out. And then a breakdown here are the services that are going to provide.

Now you notice I made a little spreadsheet here of common services. You might just have something you just fill in the. Of what you’re doing and the fee is, so that way they could know and notice I put an estimated payment. Yep. But is that something you’re going to absolutely guarantee?

No, it’s an estimate. And remember you have a $400 threshold, so it’s pretty easy for us. So the big picture for me is I want a person to be comfortable with their care that they can afford it and remember affording it is not always as complicated. Think of this. How many times have you seen a car that they advertise on TV?

Do they ever tell you the total price of the car? They never do. They always say, oh, it’s 4 99 a month. So here, we’re going to do the same thing. We’re going to tell them what the total fee is. And if that’s something that kind of rebuffs them, then you can talk to them about, Hey, no problem. We work out payment schedules for you.

We’ll debit your card. [00:15:00] Anything to just make it more palatable, but at least this way, no, one’s going to be surprised by how much. So this would be a good way of dealing with when you’re out of network, which frankly, I recommend now, what if you are in network though, here’s a different. It says here the same thing at the top, we’re going to bill, but notice it says our office and providers are in network with your insurance and put the client name.

We then talk about balance billing, which there’s none. So that’s why in the red section, you’ll notice it specifically talks about copay, which is fixed and maybe what’s excluded by example, many of you who belong to American specialty health, you understand that they do not cover massage or manual therapy.

So as a consequence, you can inform the patient that’s not a covered by. And they would be liable for those amounts, but you have to tell them beforehand. So do be conscientious of making sure when you’re making these types of estimates, that patients are clearly aware of what they’re going to pay.

That’s all there is to it. Is that really that complicated? I don’t think so. It’s just a matter of thinking just like yourself as a. What would you want [00:16:00] to know what the costs are that way, how you can afford it? And if you feel it’s unaffordable, now we, as providers can work out something for them to do that.

Now, if you’ve never noticed, if you go to our website, the American acupuncture council network, you’ll notice we have a new section. Have you ever been there? Have you seen all the information about. We’re putting out information on vaccine mandates, whether it is or isn’t no, it’s different a little bit for each state, not ma not nationally, but notice about four weeks ago, we put things up on the no surprise billing.

So one of the ways you can always get engaged and we’re here to help is by just going to our news. Our goal is to make sure you have a practice that is thriving, that’s doing better. How do you do that by having the correct information to make sure you’re getting paid? That’s our ultimate goal. So if you really want some day to day help, we offer a service, we call our network or hotline where literally you hire me as part of your staff or part of your.

And then you work with me directly by phone fax, email, even zoom, all types of issues, anything coding, billing, [00:17:00] documentation. We’re always here to help you. The American acupuncture council network. Here’s our site and our phone number. If you have any questions or concerns that never be afraid to reach out to us, we are your teammate and we want to make sure you’re doing well.

So I wish you all the best now coming up next week for the live program will be Jeff Grossman. I look forward to seeing you all at a future seminar until. Be well, take care of yourself. Take care of your family. Thank you everyone. Okay.