Acupuncture Malpractice Insurance – Your 2024 Fee Schedules



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Greetings, all my colleagues, all my friends. Welcome to 2024. This is our first show for you. This is through the American Acupuncture Council, but I’m from the network. I’m the coding and billing expert, Sam Collins, and one of the big questions I get every year is, Sam, what do I do about fees? What has changed?

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What is updated? Of course. We do a big seminar on all that, but I wanna give you a little thumbnail of what’s going on for 2024. What can we expect for fees? Were there updates? What’s going on with deductibles? Can I raise my rates? Let’s get into all that. Let’s go to the slides. Let’s talk about 20, 24 fee updates.

Now, when I say updates, does that always mean an increase? Let’s face it. For many of you who have been in practice for many years, you’ve probably noticed. Sam, my fees from insurance companies that I’ve been contracted with for years have not gone up. Particularly those that belong to groups like I don’t know, a SH and similar, you’ll find those fees have remained stagnant.

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We’ll talk about how you may be able to. Change that a little bit, but let’s talk about what’s going on for 2024. I think and under understand what our fees should be. We gotta think of how are our services valued? Who determines the worth or value? Who sets these fees? The fees are set really by the community in a way though obviously it’s gonna come back to the payer of the service.

What is the fee allowance for it? How much do we allow? What can we charge? It is interesting in our healthcare system. I’m sure you’ve noticed. Insurance companies can tell doctors what they’re gonna pay. Period. End of story. Take it or leave it. But do you ever notice that’s not the same for pharmaceuticals?

Now, that’s a whole nother topic we’ll get into, but bottom line is there is some mandates to what fees we can charge, particularly if you’re in network. So who sets the fees are gonna be the community standards, of course, for cash patients, what our patients will pay, but for insurance, who sets them? How are they set?

Part of it is gonna be something called a relative value unit. And that is the value of a particular service compared to another. The federal government has done this since the early eighties, and they do a study each year that updates the value of services from one to the other by example. Some fee schedules just use a simple conversion, a number, and then they take the relative value of your service.

Multiply that, and that tells you the fee. You’ll see this very commonly in workers’ comp in many states by example, in Texas, they’re gonna take the relative value multiply by 64, 83 or in Connecticut by 51 50 in let’s say Utah, I believe by $61 in Minnesota, or excuse me, in Michigan, they allow 200% of Medicare.

So it’s based on this relative value, the value of one service to another. I wanna give you a thumbnail of that. So you start to understand what does a service value at? I find most offices I consult often have fees all over the place. One fee, great, but then the other fee in relative terms is not correct.

So I wanna take you through how do I make sure to have relative values work for me to know the value of a service? We’ll keep it simple, but it’s not that hard. Obviously though we also have to deal with contracts. When you belong to an insurance, they set the fee for you. They tell you, Hey, join us.

This is how much we’re gonna pay you. However, it’s not gonna be as much as you’d like, but we’re gonna send you more patients. So you have to determine whether or not does that offset. Make up the difference. Can the volume make it up or is it fair? You’ll see these with preferred provider organizations like your Blue Cross’s, blue Shields, but you also see this with HMOs, particularly bigger, insurance companies like a Kaiser and that type health net, that study specific fee for that one.

But this means also the patient can’t go elsewhere. So the attractiveness is when you belong to these contracts, the patients get a better benefit, meaning less out of pocket, sometimes no out of pocket with these, but they set the fee. So you have to look at . Ooh, what is that fee? Is it fair? By the way, are there some things you can do or should do yearly to see whether or not you can get a fee increase?

’cause if you don’t ask, they’re not going to do it. Of course, you have to deal with fees, but also deductibles. What happens with deductibles? Deductibles start first a year, but keep in mind some deductibles. Based on when the patient visited, the prior year may roll over. So check the plans. Some plans may have, say a thousand dollars deductible, but any services the patient may have received from the last quarter of the year prior may apply to this year’s deductible.

I always thought that was unfair when you think about it. What if you got sick in December? Hadn’t gone to the doctor before you pay your deductible. Then January rolls around, oh, new year, new deductible, where now they’ve have a product where insurance is that often will roll that over.

So that’s certainly something to look at by example, deductibles for many types of plans can remain stagnant. 2 5500 thousands of dollars by example. The Medicare deductible did go up $14 this year. Prior in 2023 it was 2 26. This year it’s two 40. So do check that because of course deductible is the amount the patient has to pay out of pocket.

And then we have to figure out what’s that fee that we’re charging so that the patient is paying their portion? ’cause of course, you have to remember, there’s going to be co-payments and co-insurance, and let’s define that. A little bit better, I hope for you. When it comes to fees, the patient’s to pay their portion, when you belong to an insurance like a PPO or an HMO, we often turn that as a copayment.

It’s a specific set amount of money that is per the contract that says, oh, this patient pays $10 copay, $20 copay. So in other words, no matter what the patient receives, you’re gonna get some type of payment from the carrier and the patient’s gonna pay $10 or 20 a fixed amount. Sometimes it could be a percentage, though it could be 80% of the allowed rate, which means 20% of what was billed or allowed.

But often keep in mind we use the term co-payment to mean you are in network. It’s a set amount, but co-insurance would be a little different. And this is where it gets tricky when you are not in the network. What does the patient owe? That would be the co-insurance. In other words, everything the insurance has not paid.

So by example, if you bill a hundred dollars to the insurance and it pays 50, what would be the co-insurance? 50. So that means that patient would pay 50. Now, here’s where you have to be careful. What if you’re billing three different insurances and they all are being billed a hundred dollars? Same service.

One insurance pays 50, one pays 75 and one pays 90. If you’re out of network with each of those patients correspondingly have to pay you. One of them has to pay $50. One is paying 25 and one is paying 10. In other words, you’re not accepting what insurance pays this payment in full, but it’s a part of it to pay your full amount.

In other words, you’re getting paid a hundred some from the insurance, some from the patient, and this is the variation that when someone chooses to go out of network, they’ve gotta pay that entire difference. I’ve had a lot of acupuncture offices have some issues with that because what you cannot do is bill insurance as a fee, and then just simply write it off.

Unless you’re contracted. Now, when you’re contracted, that’s where the copay comes in. It’s fixed, but if you’re not contracted, it’s the co-insurance. So do be careful when it comes to setting your fees. Should you set your fee off the best paying insurance you have. Let’s face it them, there are some insurance plans that pay acupuncturists, and you’re gonna think, I’m kidding.

For some states, three to $400 a visit, I kid you not for acupuncture. That’s how much it’s valued. That’s great, but what about a plan that doesn’t value it that high? When I bill that high amount, does the patient have to pay the difference? The answer is yes. So you wanna be somewhere in the middle of what you’re gonna afford or what a patient can afford.

And remember, you always have to keep in mind my prices for insurance, if you will. Have to pretty much match my cash. Now, that can vary a little bit if you’re in the state of California. Familiar California has laws that allow you to have kind of that dual fee. But in other states, no. The cash price has to be essentially equal to the insurance price.

Maybe a small time of service discount, five to 15%. So when we’re thinking of how services are valued, it’s how do I value them? What’s their worth? How do I value it? What’s the best way for me to think about it? I think for 2024, what I hope to get more offices to do is begin to realize that if you are not doing something to update your fees, carriers will not.

By example, this year, Medicare has reduced fees, not by a lot, but by a very small percentage. They go, oh, how dare they? Has nothing to do with the doctors. Let’s face it. Is Congress and our government a little bit dysfunctional when it comes to budgeting? So of course, where do they start to cut? Will they cut other standard types or fees for Medicare?

Hence where that came from, has nothing to do with the value. It’s just, Hey, we’re gonna cut this. So realize, be careful if you’re gonna use Medicare rates. Realize Medicare rates went down this year. So this, should that mean, oh, I gotta lower my rates also? No, absolutely not. I would in fact, think, hopefully you’re doing this already.

Should you raise your rates 2%, maybe 4% a year? Absolutely. Because if you do not, how do you make up the difference of cost of living? Think of it. You can go years with the same rate and go I’m not making any more money. How would you when you’re not charging more? Because if you see the same patient volume, it’s gonna be the same and there’s gonna reach a finite point.

How many people can you see in a day? That’s not going to change. If you’re treating a person for 45 minutes, you’re gonna see maybe 10 or 12 maximum. Maybe a little bit more, but give or take, so you reach a point, you have to figure out how does this office continues to sustain when all your other increases, your cost of living prices, your cost of needles, your cost of gowns, all those things that go with your office.

So we gotta start to think of, I’ve gotta start to value and make sure am I setting the right fee? And this is where I hope to help you. Relative value units are the value or a fee comparison. Of medical services and overall, every CPT code, every single one has a relative value. And what this is based upon is the value of the service based on several factors.

The work value, the cost of delivering the service value, the cost of your education. So you’ll see when it comes even to acupuncture, there are variations that are year to year, and it simply just compares. One code to another. So make this very simple. If you have a code that has a relative value, let’s say, of 0.75, and you see another code, even if you don’t know what the code is and that code is worth a 1.0, what that should tell you is the value of the code worth one.

Should be 25% higher than the other, or 25% lower based on which way you’re moving. Because what I often find is acupuncturists in particular not understanding this way, undervalue services such as exams and therapies ’cause not understanding the real cost of them. It’s like owning a house in a neighborhood and not understanding the value of the neighborhood.

Remember when you do or sell a house, you don’t just go I paid X, Y, Z for it 20 years ago. I’m gonna charge this much more. What are you gonna do? You’re gonna look at the cost of the neighborhood. That’s what relative values do for you. So let’s look at what’s happened from 23 to 24, and you’ll notice not much of a difference.

1.14 is the value of 9 7, 8, 1 0, and 23. It moved up one percentage point in 24, 9 7 8 1 1 was 0.86 now to 0.85. But what I hope you’re seeing here, do you notice that’s a 30% difference? The big takeaway here is. Whatever my price is for my first set of acupuncture, the price corresponding below, it should be about a third or 30% less, give or take.

Now again, that means if my first set price was a hundred, what would be my second set price? About 70. That’s how you wanna think of it. I don’t wanna see you value something too low or too high. By the way, if you could tell me what an insurance pays for one code, I can tell you what it pays for the other, because every code.

Has a relative value by example. Do you know an exam 9 9 2 0 3 is worth three times the value of your acupuncture code? And I bet many of you undervalue that. So that means the price of a 9 9 2 0 3 based on relative value and cost should be three times that price. Where this helps you though, is you wanna start to think of what about the states, like I mentioned, like

Texas that they look at your RVs and give you a set fixated number to multiply 64, 83. By the way, Medicare takes this and goes by about $33. Now that varies a little bit depending on your location and state, but on average. So what I hope you can take from this is when it comes to your fees, when you’re updating this year, think of the fee differences, your difference between each code.

You’ll notice it’s about 25%. When it comes to the electro acupuncture, but you should be in the 25 to 30% range between the codes. By example, if I bill a hundred dollars for a service, but an insurance is willing to pay 120, if I bill 100, how much are they gonna pay me? A hundred, but they would’ve paid me one 20.

Have you ever noticed no one says, oh, by the way, we would pay you more . So you really wanna start to do a fee survey. That’s one of the things I do with our offices. If you do our seminar, of course, our network. I really dig into that and start looking at what’s your area? What are the costs? How do we look at the relative values?

What do other fee schedules tell us? Because you have to start thinking when you’re setting a fee, what is usual and customary for your area. What is it? The average, but also what is fair? You gotta think of, I might have an area where I could charge more, but you might say, no, Sam, I want to value it.

’cause I want to take care of the underserved group and have my practice more based on cash patients, which are per perfectly fine. But then we know that, and that could be why your fees are a little bit lower than the average. Because keep in mind it says here, may I have a dual fee schedule. Not really.

You have a service and a fee. Now I will clarify. Can you have a fee schedule that is for your ? Contracted groups, like a SH $26 $40. Sure. And then your regular insurance price. Because it’s by contract. Technically, yes. But once you’ve set a fee for insurance outside the contract, it’s pretty much the same across the board.

You’re not gonna have a hundred dollars for insurance and $50 for cash for the same service. Way too far off. Remember, you do have to collect, meaning if you’re billing a hundred and you’re not contracted, you’re collecting a hundred. If the insurance pays some portion of it, great, the patient pays out of pocket.

So start to think of for fees. What’s fair? What would I pay and what do I expect my patients to pay the value of my service? Remember, create value. People will purchase. Remember, the cheapest office is not always the most successful. In fact, often not because it’s perceived, it’s not as good a value. Give the patients good care, a fair and reasonable price.

But being cheaper isn’t always the thing. So I’d like you to start thinking of, if I’m gonna raise my rates this year, how and where do I do that? Do I use relative values? Do I look at common fees in the area? Yes, you should do all of that. I would look at your work comp fees. The simple rule might be just looking at the Medicare fee schedule and thinking what percentage above that.

’cause at least that way you’re doing relative values. It’s one of the things we give at our seminars is you get your fee schedule for Medicare and then can start to work off of that. Or even better, we work one-on-one on that, because you gotta start to think, if it’s first year, it’s time to start thinking of that.

How do I raise my fees? Do I have to inform everyone? You just raise your rates. You’re certainly gonna put notice that you’ve increased, but simply you’re just increasing. Be careful. If you’re not increasing, no one will. What? If you’re billing below what they allow, you’re simply gonna get that allowance.

Don’t be afraid to do more. And what if you are a network? Have you ever thought about asking for a raise? What things do you need to do to get that raise? You know what you have to do? Really create a value. To them show, Hey, I’ve been in your program for many years. Here’s the cost of my services. Here’s the value I bring.

I’m a tier six doctor. Let’s say you’re also an underserved. The more you can, I will say, I’ve had a few offices this year. When I say this year, I should say 23, that actually have gotten a 50% increase in their rates from managed care, particularly a SH. It’s something I’m finding is happening more if individuals are requesting it and you’re in good standing.

What I want you to think of though is that it’s first of the year, have costs of living gone up for you, gen generically. How has that gone up in your business? Have you really start to set a precedence if you don’t raise for years and then raise it 10 or 15%? People go, oh wow, but what if you raise just a small percentage every year?

Keeping yourself within range and keeping in mind how to balance whether you want more cash or more insurance. But what I’m careful of is if you’re not mindful of your fees in your store, no one else will be. I’m gonna say patients at the end of the day are gonna be the ones that are gonna dictate what can I charge?

I. What insurance is allowing. That’s not gonna be the end all be all, but it gives me a feeling for it. What about my contracts? How do I make those work? That’s what we do with the network. It’s what we do with our seminars. This just is a thumbnail start to learn how to really make your practice do better.

And it’s not just about insurance, it’s about everything and being successful in enjoying what you do. The American Acupuncture Council is your partner. We want you to be successful because if you’re not, you have no need for our services. We are partners. Good luck and best wishes for the year. . .


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