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Acupuncture Malpractice Insurance – Are You Ready to Request A PPO Rate Increase?



So is there a way? To request or to get an increase in a PPO rate, because if you think of it, they never do it, but is there an opportunity to do yeah…

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Greetings, my friends. This is Sam Collins, the coding and billing expert for acupuncture and for you, but the profession as a whole. Thank you, American Acupuncture Council, for the opportunity. But let’s get into it. What’s going on, particularly for the first of the year? You’re always thinking business, money, pricing, and many of you have joined these HMO slash PPO plans and may have been in them for years and are noticing them.

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I’m getting paid the same thing, year after year, and at some point that becomes unsustainable. So is there a way? To request or to get an increase in a PPO rate, because if you think of it, they never do it, but is there an opportunity to do yeah, I will certainly say I’ve had offices that have had success in getting rate increases for PPOs, but there’s a way to do it that I think will lend to potentially having more success.

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This is no guarantee, but potentially more success in getting a rate increase. So let’s go to the slides. Let’s talk about that. What things do we need to do? To help ourselves request a rate increase and really get one, it comes down to making sure you create really a value opportunity about your office.

I want you to write a letter to them and request specifically an increase, but by writing a unique value proposition that makes your practice stand out. Maybe where you’re located. Okay, it might be an underserved area. Those types of things are helpful, but more than anything, always go by what’s your status within the plan.

Show your value. I’m sure many of you have heard of the company ASH or one similar, and you can rise in status from Tier 1 to Tier 6. Obviously, the higher tier status you have, The more prestige you have in the plan, and that creates more of a value. They want to keep those higher performing providers, and if you are one of those, that certainly makes it much, much better.

You want to also focus in on your utilization. Bear in mind, we do understand these plans raise your tier by not over utilizing care. That doesn’t mean you shouldn’t do the care that’s necessary, but be mindful, they’re not expecting everyone should get 20, 30 visits. They’re expecting, actually, an average of about 8 visits per patient.

And what that means is, you’re going to have some patients that you might see 20 times. They need it. There should be a balance with maybe seeing some of them two times, so that average comes in. Realize, don’t let one patient plan set it up, but the average over time. And if your numbers are lower, you can show that.

You would point out, heck, my average is six, let’s just say. You want to also highlight, what about the number of providers that might be in the region? Some areas are very underserved. Particularly now with the viability of acupuncture, the VA and all these things, they’re looking for providers. And if it’s an underserved area, that’s going to help.

But even if it’s over served, if you will, there’s a lot of providers. Where do you stand out? Your availability, your location, your hours. Your languages you speak. What if you have multiple languages? I would highly recommend if you have multiple languages spoken in the office, it should be brought up.

Do you speak Spanish? Do you speak Tagalog? I mean think of any type of language. It’s gonna be helpful to create access because that’s very important these PPO plans always creating access. Make sure you also point out their value Compared to other existing contracts. Other plans you’re part of, but I would start with Medicare and Workers Comp.

My goodness, even Medicare for two sets? When you look at the Medicare rate, it allows 70. Workers compensation is usually a percentage of that. Usually anywhere from 120 to as much as 200 percent of Medicare. So therefore, you want to start to use that to say, how is it a PPO thinks they’re sustaining when they don’t even meet the value of Medicare?

And Medicare is the low end. ASH is going to pay many acupuncturists 40 to a visit, which is literally one set, even for Medicare. And if there’s two sets for Medicare, you get 70. So it’s probably unsustainable, and it’s not reasonable, really. Because you have to look at inflation and cost of practice.

Don’t be afraid to bring up about your own specific issues in your practice. What does cost more? Certainly, when you first started practicing, your rates have increased. I’m looking at rates of rent now, which are through the roof. Could that be sustained? Look at gas, the cost of phone and internet, all those things are part of a practice and cost.

So you have to make sure that you’re creating all of that with the window to show your value and unique value to that plan of how you’ve helped people. Don’t be afraid to get a few testimonials from patients of how you’ve helped them. Make sure there are ones too that the patients didn’t have something where they needed hundreds of visits to.

But nonetheless, those types of things are going to be helpful because an insurance company has a vested interest. and making their clients Happy. You want to show that’s what your job is and what you have done. So here’s a way to focus that. This would be the highlights of how to put together some type of proposition or letter to the carrier.

And you can point out, I’ve been a panel provider since say 2015. For some of you, it might even be longer. I support the development of managed care in acupuncture because it helps to standardize documentation, promote evidence based care, and create greater accessibility. We want people to have access to get acupuncture.

We do. But we’ve got to make sure in doing so, we have to have a reasonable amount that’s paid to us to sustain it. You’ll highlight to them there’s been no significant change in reimbursement from your plan, and I’ve been a member for decades maybe. These days, I’ve increased costs. Staff salaries, rent.

Think of the work we have to do now with electronic health records, electronic billing. All the costs that are there. A lot of these plans require you to bill electronically. That doesn’t happen for free. Therefore, that’s got to be brought in. Software contracts and so forth. Not to mention your rent and the other things that go with maintaining your practice.

And frankly, the cost of other things. Cost of gowns. Cost of needles. It’s all increased. You’ll highlight to them, my overhead is nearly four times of what it was when I enrolled with you. My average cost of seeing the patient now is 41 a visit before there’s even a profit. So some of these plans are paying as little as 40.

So you got to think, wait a minute, if my cost is 41 and I’m getting 40, does this make any sense? No. Can you imagine every business just exactly makes what their actual costs are? You can’t stay open. There’s just no way. So this level of reimbursement is not a sustainable model, and while being on the plan to create a greater volume of patients, there’s still a limitation.

Let’s face it, an acupuncture visit is typically 30 to 45 minutes. How in the world can you sustain a practice where you’re getting paid? Less than 80 for an entire hour of work, maybe an hour and a half, and then going to be able to maintain that practice to be open. Think of just what you’re paying per square foot.

In some ways, I would argue we might be better off working at Starbucks or Panda Express, considering some of those places pay 40, 000 to 80, 000 a year. For a full time worker. Come on, as a healthcare professional, they can’t have rates that are at least sustained at that level. So you want to start to point out that hypocrisy by pointing out the rates for your insurance have increased to allow the plan to remain solvent.

I get that. Has insurance companies increased the rates to their insurance every year? I know and I redo my insurance every September. There’s been an increase every year I’ve been in there. However, are providers part of this increase? Isn’t it interesting how insurance companies typically say we’ve had to increase the rates because of the increase in cost.

And I agree, there’s an increase in cost. Where isn’t there an increase in cost? What provider is still getting the same, paid the same amount they have for years? So in reality, the provider costs are flat. Yet, they get all these raises to do what? Now maybe that’s to cover drug costs and all that, but at the end of the day How could they say we’re part of an increased rate when they’ve not paid us any more money?

They’re thinking you just can see more people. How could we see more people if it takes that much time? So it’s unreasonable for providers to bear this cost with no consideration, while the plan has increased their premiums and the adjustments in pay to their workers. If you work for these plans, I bet many of them, if not everyone, get some type of adjustment yearly, 2 to 3 percent.

I’m looking at least for that. I would think if you haven’t had one in a while, what about a 10 or 20 percent jump for this year? Because to sustain it in this way at some point just cannot be sustained. In my observation, healthcare services are the cornerstone of this business and have been left out.

I’m requesting if you’re getting per diem or even if it’s per service, a certain request over that, which will allow me to continue to welcome these patients to my office in the future. Because without an increase, I will no longer be able to sustain the relationship. Let’s be reasonable. It just won’t.

In fact, I’ve had a lot of offices that realized that it was a sum negative and they’ve dropped out. And this is someone I spoke to last week. This is not an exaggeration. They pointed out that they dropped out of one of these plans and they first were very panicked because they thought, Oh my God. And they go, Oh my God, Sam.

In the first two months, they lost 30 percent of the patients. But here’s what they realized. They lost 30 percent of the patients, but that only equals 6 percent of the revenue. What does that tell you about this plan? How bad it is? All this work and emphasis. Maybe it’s not worth it. And this is something that you have to start to look at as a business decision.

There’s nothing wrong with being part of these plans if they’re at a sustainable rate. But if they’re not, maybe it is time to move on. And this is what we look at. If they can’t sustain it, then let’s move elsewhere. Don’t be afraid to make a move. Don’t be afraid to request. Because at the end of the day, the power is with the providers if we wield it.

And don’t be afraid that ultimate power is your patient. And if that patient is still coming in without the plan and paying a fair rate, why would I push for this thing where I’m getting paid 25, 30? So do be careful, but I’m not saying not to request, not to do it, but at least this way you’ll know where you stand.

And if they’re treating you that poorly, maybe it’s time to move on. Don’t be afraid to break a relationship that relationship does not have mutual parts that are beneficial to both sides. And that rate increase to us, I think is important and without it, maybe we can’t stay there. So don’t be afraid.

I wish you well, as always, the American Acupuncturist and myself are always there to help our service. The network is a place where you can go and work with me one on one to really write up a protocol like this. I really wish you all well, continue a good practice and enjoy what you do.

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