What I want to focus on is the medical necessity of acupuncture. How do we define it? What is it? And then how that leads to pre-authorization as I’m sure many of you have noted acupuncture has become very well covered by lots of plans.
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Hi, everyone. Welcome to another edition of the American Acupuncture Council malpractice, To The Point, getting your practice better, making your practice improve on many facets. My job as always is to talk about the acupuncture and getting paid for it. How do we create that business model? Today’s edition.
What I want to focus on is the medical necessity of acupuncture. How do we define it? What is it? And then how that leads to pre-authorization as I’m sure many of you have noted acupuncture has become very well covered by lots of plans. Aetna now mandates it. I If you’re in Massachusetts, it’s mandatory on their coverage.
And of course there are five states with acupuncture. That’s mandatory, but many plans now are covering acupuncture, but let’s even go beyond that. What about a cash? I want to focus on a little bit on both of those in the sense of let’s talk about what is necessity, how do we define it? And then how do we use that to get pre-authorizations?
One of the things I deal with quite a bit, and being an expert on coding, billing, documentation and collection is, Hey, how do I get them to approve more care? Particularly if you do the VA. Premera or Ash, any of these types of plans. So let’s go to the slides of room. Let’s talk about the medical necessity of acupuncture and pre-authorization as always, there’s our website and there is my email as well.
Let’s talk about what is medical necessity of acupuncture? How do we define it? And I think you really have to look at it in two ways. It’s really the same, but two different ways you have the patient and you have the third-party meaning. If someone else is paying for it, if you’re paying for something you want to make sure there was service was provided and it was needed.
So from a patient standpoint, let’s think what does a patient need for medical necessity? I come to you. I don’t feel good. I’m in pain. What am I looking for to reduce my. So medical necessity for a patient is, does it work? Does it accomplish why went to which is an always pain management? Obviously acupuncture can treat more than just pain, but you get my point.
Let’s keep it simplistic on the pain level. Did it improve it? Let’s face it does pain medication. It does. You, if you take enough Vicodin or, something more S more significant what it reduced the pain. Sure. But then what is the outcome you’re asleep?
You don’t feel the pain cause your body’s knocked out. So does that really improve anything? So from a patient standpoint, they’re not just looking for pain, Redux. But improvement of their life improvement of their activities of daily living. And so from that standpoint things, but medical necessity for a patient is either they’re getting better or they’re not, if they’re not getting better, what did they do?
They stopped coming simple as that. When we deal with it from a third party, meaning someone else’s. Let’s say a parent is paying for a child. If it’s not working there to stop having them come well, insurance works the same way they want to make sure is the patient getting better. And I think this is where agriculturists often have a hard time.
Acupuncture works very well, as you all know, but I will go back to, did you demonstrate it that’s really going to be an important factor. How did you document that the patient got better is a statement. Like I feel better, really adequate. Think of it like a person. If you put someone on a diet and they go, oh my God, I feel better.
I have more energy. Those are good things, but what’s the purpose of the diet for the. Is to lose weight. So we need evidence of weight, loss, or evidence of reduction of pain. So let’s take a look at how does insurance define this, and this is an Anthem policy, their newest guideline notice just from this year.
And this was their typical acupuncture guideline. Now, with this, it gets a bit confused when it talks about medical necessity and mostly it gets into the types of things that they allow you to treat nausea, vomiting, chronic pain, and so forth. But I want to highlight this. It says the individual being treated continues to experience one or more of the conditions listed above and the requesting physician documents ongoing benefit from the use of acupuncture.
So what is going to be the. Or reduction of these how do we demonstrate it? Is it going to be enough to say I feel better? And I’m going to say probably not let’s take a look at like Aetna, here’s the epic policy when it comes to acupuncture and it talks about the types of things they’re expecting.
And the main thing they’re expecting is this, the plan of care should be ongoing, updated as a matter of hours, condition changes, meaning we have to have evidence of change and are considered medically necessary. Only if there’s a reasonable expectation. That acupuncture will achieve measurable improvement.
This is where I think we have difficulty. A statement of, I feel better is not really measured. So we have to somehow try to attempt to quantify that. And it says, of course the patient should be evaluated regularly. The bottom line is treatment goals and subsequent documentation should result in that.
There’s an achievement of a change. What if we’re saying a pain reduction, we have to stay to such by how even a numerical pain scale while not perfect, at least give some evidence of that. But I’m going to say to you that’s not enough when it comes to pre authorizing care. If you’re dealing with a premier Ash, a statement of reduction of pain is good, but they want a little more evidence.
So let’s take a look at what they all say. Maintenance treatment is where the member symptoms are. Neither regressing or improvement is considered not medically necessary. So keep in mind a lot of times you’ll say the patient’s not getting worse. And while I don’t disagree with that, they’re going to question well, if they didn’t get.
They not get worse. So we have to be able to have some ability to prove it. So this says here, if no clinical benefits is appreciated after four weeks, then treatments should be reconsidered. In other words, they’re not expecting the patient to be better overnight, but some measurable change will even Cigna gets in the mix here.
It talks about it’s protocol. What I’m showing you here is from each carrier. So that way it’s not just Sam getting opinion, but what did they stay that. They say standardized tests and measures a functional outcome measures. And it says measuring outcomes is an important component of acupuncturist.
Practice. Outcome measures are important in direct management of individual patient care and for the opportunity to provide the profession and collectively comparing their results to others. How do we know ours is better? We compare it. So here’s what it says. Second paragraph, the use of standardized tests and measures early in an episode of care, establishes a baseline of status for the patient.
Providing a means to quantify change in the patient’s home. Outcome measures along with other standardized tests and measures used throughout the episode. In other words, we’ve got to measure things. So be careful of, I feel better. That’s good. But when they say they feel better, I want you to measure it simply this way.
When you say your pain is bad, give me a couple of things that you can’t do or have difficulty doing because of the pain. And then as it improves, How have those change. So you want to start to think of, I want to use tools to make this easy and what I want to point out, this is quite easy. I would even say an acupuncturist could have mediocre documentation so long as you’ve documented the aspects of the care that was delivered, the time the services.
And ultimately the outcome, the biggest thing is what is the outcome of the patient? So I like to take ever, of course, behind the scenes for United Anthem and a lots of policies, including Optum. And here’s what they say. One thing is you should use a pain scale. Don’t just tell me their pain is hurting.
Give me a level, the only problem with the pain scale. How do we really measure what is the difference between a seven and a five? So what I believe, and it may be even a better tool. So take a look of what it talks about here, about functional measures, and you’ll notice a common theme, documentation of a patient’s level of function as an important aspect of patient care.
The documentation is required in order to establish medical necessity of ongoing acupuncture treatment. It says the patient specific functional scale of the PSF. Is a patient reported outcome that is easily and appropriate for acupuncturists to demonstrate the care. So keeping it simple, don’t think it has to be very hard, but keep simple things of a patient’s telling me not so much how much it hurts, but how pain affects function.
In fact, I’m going to give you a tool today that you’ll be able to take away from this presentation. So what this is all pointing to is that medical necessity comes down to data-driven. Tracking changes and restrictions of activities that they live, not just paying. Cause if pain was the only measurement, heck we might as well take pain medication, but pain medication, of course, all the other side effects.
And the fact that there’s no increase in function, it means it’s not quality care. So we want quality care that not only reduces pain, but increases function. And that’s frankly, what you do think of how many times all of you have had this miracle in your office. A patient comes to you. They’re basically.
And they’re saying I’ve been to a Cairo, I’ve been to medicine, I’ve tried this, that physical fit. They tried everything and they figured what the heck I’ll let acupuncture give it a shot. They come in and after a visitor too, they’re like, oh my God, I can’t believe it. Think of the. Of that.
I bet some of you became an acupuncturist because that happened to you. What we have to do is deliver that in a way that not just that the patient sees it, but that we’ve documented them, seeing it, think of it. Have you ever been to a medical doctor? And I don’t say this as a negative, but that’s not the way they treat.
If you ever went in and you left going, God, I feel so much better. My headache is gone. That’s not the way they treat. They prescribe the send out of their information. You have the power of someone can come in with a headache and literally leave. Was it before. That’s the powerful. That’s a value that patients want.
We have to make sure did we demonstrate it. So I want you to thinking along the lines of something we call Promus, this is the new term you’re used to outcome assessments, but this term promo stands for patient reported outcome measurement instruments. And you’re familiar with many of these Oswestry, the low back one neck general pain index.
I want to show you some examples to implement some easy ones to don’t make your life too complicated, because frankly, as much as I like this is the one for the Oswestry for local. That’s 10 questions. That’s a lot of information. Will your patients really adequately fill this out accurately? Every time you do it, to make sure you really have got a valid assessment.
And I’m going to say in many instances, no, if you’re going to use this one, I would make it part of the history or exam that you ask the questions because your patient may not remember what they said last time. And how many times have you had a patient tell you they feel better? But yet their pain scale, they note it was higher.
You’re going to go wait, that doesn’t match because they don’t remember. So this is good, but is it sometimes not as valid because patients just simply don’t fill it out accurately. So I’m going to recommend something simpler. This is called the general pain index. I particularly liked this one because it covers almost any condition.
I don’t care if they have headaches, abdominal pain or knee pain, because what this does is it focuses not on how much it hurts, but more about the function. So notice each question. Family and home responsibilities, recreation, social employment, and so on are focused on not how much it hurts, but your ability to function.
If you have good function, it’s a zero. If your function is reduced, it could be, completely it’s a 10. So the higher, the number of them when the patient scores this, the worse off they are. So we do this at the beginning. Maybe they score 30 points. After two weeks of care, you do this again. Now they dropped down 10 or 15 points.
It’s clear evidence. Objective. Of how the patient has changed, not about how I feel, but the function part of it. You correlate that of course, with other objective findings. How about this one? This is something new called the pain interference, and this is something the VA is really pushing and you’re going to notice, we’ll see them.
That’s pretty much the general pain index, except it’s just not as detailed notice. There’s only five ways to report this one, as opposed to the tenants. Where it’s interfere with day activities from a little bit too very much. It’s still good. I just don’t like it as much because it’s not as quantified, but this is when you could do weekly.
I prefer something with numbers, frankly, because it’s a little bit easier to score, but this is a good tool as well, because this is the evidence of the change. If someone’s losing weight, when you put them on a diet, how do you prove it to I’m on scale, then the next time you use these scales. So think of it when you’re going to make a request for services.
We have to have something we can provide to show that the patient’s gotten better. So I’ve taken this from the VA’s requirement for increasing or for requesting additional care. And it says what they’re looking for, a significant durable pain intensity. By functional improvement by clinically meaningful improvement on validated disease-specific outcome instruments.
Oh my goodness. Where have we heard of this? Do you see the consistency here? And of course, if there is any reduction of pain related meds as well, but it says here, objective measures demonstrating the extent of meaningful clinical improvement today. And the rationale for treatment requesting care is what they need.
Show me that the patient, Hey, they’ve improved 20% after two weeks of care and it’s been considered. Why wouldn’t we continue that care until they’ve reached a point of plateauing where there’s not any improvement, realize that so long as the patient’s improving, there’s a reason to continue care when the patient plateaus at a certain point, obviously that’s when we put them on a maintenance, stylish means not covered by insurance, but at least something where the patient can know the value of it.
And notice it also indicates including any barriers to recovery. So you want to think along the lines of, do I have information that someone reading it could go, oh yes, this is what. A statement of, I feel better. Isn’t that valid. So let’s take a look at a medical necessity when it comes to American specialty health.
This is the one that probably can be some of the strictest. What things do they rely on diagnosis? Of course, past history. Those things obviously creates the Verity, but comorbid factors, but notice what they look for, findings things that you can objectify range of motion, palpatory, tenderness, orthopedic testing, neurologic testing.
I’m not saying you have to do all of these already. But you have something that you have to have objective, even if you’re doing tongue and pulse. Tell me what’s better. Give me a way to show on paper. If you will, how the patient is better in a measured. So functional limitations is something they rely on as well.
In fact, if you’re used to the pre-treatment authorization forms and that includes Ash Evercore, Premera, they all refer to these. So I’m just going to say, make your life easy, begin to use the simpler outcome assessments. And I would suggest initial visit and probably every two weeks, but no greater than once a month, understanding that the whole goal is to reduce pain, but more so increased function.
So I’d like for all of you to think for a moment, how am I going to make this happen? We can be a good source for the American acupuncture council of course, is your malpractice carrier, but we also help you with these types of issues for any of you that have our outcome or our our AQI code.
We have all of these forms on there. Take a look, do this QR code. Certainly you can come to our site, take a look at our information. What I want to make sure is that, do you have the right tools and places to go? We’re always going to be a resource for you. I’m going to say to you, if you have any. Where are you going to go?
Don’t Google it. Come to the experts at the American Acupuncture Council. Thank you for everyone. I’ll see you. Next time. .