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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.
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.
Osteoarthritis pain can limit walking, sleep, work, and everyday independence. For patients seeking nonpharmacologic options, acupuncture may offer modest relief—especially for knee osteoarthritis—when it is used as part of a broader care plan rather than as a replacement for appropriate medical evaluation, exercise, or other indicated treatment.
The most defensible answer is: it may help some patients, with the strongest evidence focused on knee osteoarthritis. The National Center for Complementary and Integrative Health states that acupuncture may help relieve osteoarthritis pain and identifies knee pain associated with osteoarthritis among the pain conditions for which acupuncture may be helpful.
The 2019 American College of Rheumatology/Arthritis Foundation guideline conditionally recommends acupuncture for osteoarthritis of the knee, hip, or hand. A conditional recommendation is not the same as a universal endorsement. It means the intervention may be reasonable for selected patients after considering the evidence, patient preferences, accessibility, cost, comorbidities, and alternative options.
Recent reviews continue to report improvements in pain and physical function for knee osteoarthritis, but the magnitude and certainty of benefit vary. Differences in acupuncture technique, treatment dose, comparison groups, trial quality, and the design of sham acupuncture controls make the literature difficult to interpret as a single, uniform body of evidence.
Acupuncturists should avoid presenting acupuncture as a cure for osteoarthritis or as a treatment that rebuilds cartilage. Osteoarthritis is a chronic joint disorder with structural, mechanical, inflammatory, neurologic, and psychosocial contributors. Symptom improvement does not establish reversal of joint degeneration.
A more accurate patient-facing explanation is that acupuncture may reduce pain and improve function for some people, particularly those with knee osteoarthritis. Response is variable. Some patients notice meaningful changes, while others experience little or no benefit.
Comparisons with sham acupuncture require care. Some studies find small differences between verum and sham acupuncture, while both groups improve compared with baseline or usual care. Sham procedures may not be physiologically inert, and trial context can influence outcomes. These issues do not justify dismissing the evidence, but they do limit strong causal claims about point specificity or mechanism.
Knee osteoarthritis has been studied more extensively than hip or hand osteoarthritis. Clinicians should not automatically generalize knee findings to every joint. For hip osteoarthritis, hand osteoarthritis, spinal degenerative disease, or mixed pain presentations, the evidence base is more limited or less consistent.
When discussing research, identify the joint studied, the comparator used, the duration of treatment, and whether benefits persisted after treatment ended. This helps patients understand that “acupuncture for arthritis” is not one standardized intervention with one predictable outcome.
Acupuncture is most appropriately framed as one component of multimodal osteoarthritis management. Depending on the patient, a coordinated plan may include therapeutic exercise, strength training, weight management when relevant, physical therapy, topical or oral medications, bracing, injections, sleep support, behavioral strategies, or surgical consultation.
Before beginning treatment, confirm that the diagnosis is established or that the presentation is suitable for conservative care. Acupuncturists should remain alert to symptoms that require medical assessment, including acute trauma, inability to bear weight, a hot or markedly swollen joint, fever, rapidly progressive symptoms, suspected infection, unexplained weight loss, neurologic deficit, or possible inflammatory arthritis.
Document baseline symptoms and function using repeatable measures. A numerical pain rating alone may miss clinically relevant change. Consider tracking walking tolerance, stair use, sleep interruption, range of motion, sit-to-stand ability, medication use, and validated instruments such as the WOMAC when appropriate to the practice setting.
Set a defined reassessment point rather than recommending open-ended care. The treatment plan should specify frequency, expected time to reassessment, measurable goals, and criteria for modification, referral, or discharge. If meaningful improvement does not occur after a reasonable trial, reconsider the working diagnosis, treatment approach, adherence, comorbid contributors, and need for co-management.
Traditional Chinese medicine may describe osteoarthritis-related pain through patterns involving Bi syndrome, qi and blood obstruction, cold, dampness, deficiency, or other individualized findings. These are traditional diagnostic frameworks and should not be presented as established biomedical mechanisms.
Biomedical hypotheses include modulation of nociceptive processing, endogenous opioid pathways, autonomic activity, local tissue signaling, and inflammatory mediators. These mechanisms remain areas of active investigation. Mechanistic plausibility is not the same as proof of clinical effectiveness, and animal or laboratory findings should not be used to promise patient outcomes.
Potential benefits include reduced pain, improved physical function, and support for patients who prefer a nonpharmacologic option or cannot tolerate some medications. Acupuncture may also be integrated with exercise and medical management without requiring the patient to abandon conventional care.
Important limitations include variable treatment response, inconsistent protocols, uncertainty about optimal dose, limited evidence for some joints, and the possibility that observed benefits may be modest. Cost, access, and insurance coverage may also affect whether a trial of care is practical.
Acupuncture is generally considered safe when performed by a qualified practitioner using sterile, single-use needles and appropriate clinical procedures. Common adverse effects include temporary soreness, minor bleeding, bruising, lightheadedness, or fatigue. Serious complications are uncommon but can occur, including infection, nerve injury, or organ puncture associated with improper technique.
Review medications, bleeding risk, pregnancy status, implanted electrical devices when electroacupuncture is considered, immune status, skin integrity, prior joint replacement, and relevant medical conditions. Use informed consent, appropriate clean needle technique, careful positioning, and complete documentation. Coordinate with the patient’s physician or other treating clinician when symptoms change, the diagnosis is uncertain, or the patient is considering changes to prescribed medication.
A balanced explanation can be simple:
“Research suggests acupuncture may reduce pain and improve function for some people with osteoarthritis, especially knee osteoarthritis. The benefit varies, and acupuncture does not reverse joint damage. We will use measurable goals, reassess your response, and coordinate with other care when needed.”
This language supports informed decision-making without minimizing uncertainty. It also avoids guarantees, exaggerated claims, and the implication that acupuncture should replace treatments with stronger evidence for a particular patient.
Acupuncture may be a reasonable adjunct for selected patients with osteoarthritis pain, particularly knee osteoarthritis. The evidence supports cautious optimism—not promises. Acupuncturists can provide higher-value care by using clear outcome measures, realistic treatment trials, appropriate referrals, informed consent, and coordinated management.
Clear informed consent, defensible documentation, and appropriate referral decisions are essential when treating chronic musculoskeletal pain. Review the American Acupuncture Council’s informed-consent guidance and risk-management resources for practical support.
Educational disclaimer: This article is intended for educational purposes for licensed acupuncturists and other healthcare professionals. It does not provide medical or legal advice, establish a standard of care, or replace applicable laws, regulations, professional judgment, patient-specific assessment, or consultation with qualified medical and legal professionals.
I’ll be speaking on the heat of summer and how to… how we can support children and adults through this period of time through the summer months.
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.
Hi, my name is Moshe Heller, and I’m from Motion Herbs and also from The Motion Center in New York. I’d like to thank the American Acupuncture Council for letting me present this topic today. And today we’ll be speaking… I’ll be speaking on the heat of summer and how to… how we can support children and adults through this period of time through the summer months.
So you can go to the slides
All right. In the past right now we have just passed the summer solstice on the 21st of June. And we have in the past two months have already experienced a few heat waves, and it was very hot here in New York at least. And but the weather here in New York has actually been quite fluctuating and we’re having hot days then we’re having really cool days which is usually a cause for illness, right?
That’s these weather fluctuations is that, is the time when we are exposed to pathogens and we can be hit by heat or cold or wind combinations. So in the summer, we usually expect more of the warm disease, summer heat, and a lot of digestive issues, a lot of damp and heat here in New York, especially.
And those are the de- disease patterns that we expect. But in this summer which I’m usually not concerned about having too much external pathogenic fa- factors influencing my patients I am actually thinking about that and supporting how can I support my patients better in these weather fluctuations.
I’d like to talk about this formula, which at Motion Herbs we call Shield. But it’s really based on a very traditional formula, which we know as Yu Ping Feng San or Jade Wind Screen. And I combine that this formula with Wei Ji Tang which helps to harmonize the yin and the wei. So these formulas together strengthen the exterior, but also harmonize the functioning of the wei and the yin qi so that if we encounter a pathogen, we can effectively resolve it very quickly or without, or not let it invade So when I formulated Shield, I wanted to make sure that the qi is supported and also the huachi, the transformation and transportation is complete.
And for this we added the combination of Ban Xia and Chen Pi, which we s- we know as the formula Er Chen Tang or two cor– two, two, two cured decoction. That will help in transformation of dampness and that usually this dampness, if it accumulates, can hinder the function of the spleen.
And we also… I also added Tai Zi Shen which we call Prince Ginseng. And it allows the formula to support the qi and the yang, but also is m- very much appropriate to children. It also supports the formula’s ability to to support fluid generation so it’s not so drying. In addition, we added Wu Wei Zi which helps to consolidate the exterior by bringing the kidney support to the lungs and supporting the exterior finally, we a- also added Ge Gen to harmonize the muscle layer and and support digestion, and Ling Zhi which is an adaptogenic mushroom and considered a potent immune system tonic.
So together it creates a very nice protection for the exterior and is something that I definitely use during winter and fall time. But in this summer I feel that patients need that added support Here you have a little bit of a structure how its shield is built. And then I want to also talk about another formula which traditionally is called Kan Ning Tang or curing, the curing pill.
This is a great preventative formula for summer digestive issues and external pathogenic factors that might be have a warm nature to them. It’s a very effective formula that a patent formula, you can get that in many Chinese herbal stores as well as different companies make version of Kan Ning Tang.
It’s you can see that this formula has a lot of herbs that drain dampness and relieve the exterior. And therefore, it’s really good for different varieties of stomach viruses or what we might call stomach heat if that is something that’s happening. On the same token, there is the other famous formula called Bao He Wan, which Motion Herbs also has a version of that which is from the Yin Nourishing School of Zhū Dānxī.
This formula really helps with reducing food accumulation if we’ve been out and eating too much and there’s some food stagnation that needs to be resolved. You can think of Bao He Wan or Digest to support that issue. So we’ve modified Bao He Wan a little bit to clear some wind heat and regulate the qi.
We included formulas herbs like Lian Qiao, Ge Gen Zhi Qiao, Ju Hua, and Tai Zi Shen similar to the ones that we had with Shield. That will support the body’s s-spleen and stomach functioning and also in case there is an external pathogenic factor, relieve that aspect of that Here’s a presentation of Digest.
You can see how the herbs are distributed. And then I created this kind of combinations that support the same aspect in terms of acupuncture. Du 14, we know clears heat as well as large intestine 11 in cases that there’s we need to clear heat from the digestive system.
Supporting the, the spleen and stomach with stomach 36, supporting s- spleen and stomach qi, as well as spleen nine to help drain dampness that may have accumulated. Stomach 25 to regulate the intestines and pericardium six if there’s any nausea involved with the heat invasion. And sometimes I will combine heart six and kidney seven if I feel that there’s an imbalance in the Shaoyang, meaning that there’s some heat that’s rising, and to bring heat down back to its source, we use this combination just as a closing remark diet in, in the summer is the the season of the fire, the yang, the growth and maturation, and therefore the food we eat has to reflect that.
Very light and colorful from all colors. Lots of vegetables that are in season. The, the… I think one of the most important thing that we have to remember is that our diet should always be according to, Chinese dietary recommendations to include a large amount of vegetables more than anything else.
I know that today most people are concerned about how much protein they’re getting in their diet, but I’m always concerned of how much vegetables you’re getting in your diet more so than the protein. That’s extremely important that we get a wide variety of different colored vegetables as part of our meals.
Cook lightly. Don’t make it too heavy. Steaming, sautéing, grilling are great ways to cook during the summer. Use slightly spicy and pi- pungent spices like ginger to warm up the interior and some bitter taste to drain heat and regulate the heart. For example a great vegetable to be eating during the summer is broccoli rabe which has a little bit of bitterness in it, and you can sauté it or steam it.
And that is a great way to get some bitterness into your food. So although we think that in the summer we dream of all these cooling foods like watermelon, etc., which are good in reg- in small quantities, but I want you to remember that in hot places usually we eat warm foods because if we wa- warm and spicy actually foods, if we warm the interior, there’s less of a difference between the interior and the exterior.
So it actually allows our body to maintain a better equilibrium if we warm the inside of our body rather than eating cold or iced things, then our interior becomes cooler and therefore there’s a bigger difference and heat can be much… has a stronger effect on our system I’d like to thank you for listening.
We are– If you want to have more information about our herbal line please log on to motionherbs.com. Also, we at Jing Cheng Pediatrics, we are doing some hands-on seminars for pediatric techniques. Thank you very much for your time, and thank you… I would like to thank the AAC for allowing me to speak, and have a wonderful day.
So today, I am going to speak to you about how we can clinically work with these patterns through motor points, scalp acupuncture, facial cupping, facial gua sha, submuscular needling auricular muscles, and facial acupuncture points.
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.
Hi, this is Michelle Gellis, and I would like to thank the American Acupuncture Council for giving me this opportunity to speak to you today. So in part one, I spoke about the feedback loop between the face and our nervous system and our organs. And just as a little review, what I had said was that every time you treat the face, you’re treating a feedback system.
You’re not just smoothing a line or lifting a contour. You are interrupting a loop that may have been running unchallenged for twenty, thirty, forty years, and this is extraordinary work. And it is work that no neurotoxin can do because neurotoxins silence the conversation between the face and the soul.
We, as acupuncturists, can restore that So today, I am going to speak to you about how we can clinically work with these patterns through motor points, scalp acupuncture, facial cupping, facial gua sha, submuscular needling auricular muscles, and facial acupuncture points. So I’m going to speak in very general terms.
If you want more specific information about treating the face and how to work with this whole emotional feedback loop, in my book, “Treating the Face,” I have a chapter that covers, It’s called “The Anatomy of Expression.” And I also have a full-length recorded webinar on the anatomy of expression. So I’m gonna talk about this from two different angles.
One is if you were just to look at the individual muscles that are used to express these emotions what would be the easiest way to deal with the muscles would be facial motor points. And so for each facial muscle of expression, there are different motor points on the face that we can use to bring these muscles that may have atrophied from years of neglect, not using them, or which are overused and are becoming very tense and tight from being used too often.
Either one of these can cause dysfunction and disharmony, and in the case of cosmetic acupuncture, can cause pain. I’m sorry, can cause wrinkles. And in the case of neuromuscular acu-acupuncture, can cause pain, neuropathy, and things of that nature. And as I discussed in part one, I really got into the emotional components of all of this and what that can do, not just for our relationships with other people, but especially for young children who use their the facial feedback loop to learn how to make emotions and feel emotions.
So the motor points are great for just looking at individual muscles of expression and treating them. But we also have other tools. If muscles aren’t functioning properly, we can use scalp acupuncture and look at the area of the scalp that is involved with facial expressions facial muscles rather, which make our expressions, because on the face, the muscles are connected directly to the skin.
And in order to fully express and move the skin, you need to have functioning muscles, whether that’s for anger, sadness, happiness grief, worry fear. All of these expressions require different muscle groups Additionally, in addition to motor points and scalp acupuncture, another tool that we have is sub and intramuscular needling of the muscles on the face.
We can use our needles to either go underneath or through some of the muscles in the face in order to bring the muscles into proper functioning and bring them into good health. So for example, if our patient has gotten Botox and they no longer want to have their forehead paralyzed we can use our needles through submuscular needling and also through motor points.
For example, for the corrugator, we could use the motor point for the corrugator, which is slightly lateral to bladder two, and we could also needle underneath the corrugator, and this will help to, Once the neurotoxin has settled, you wanna wait about three weeks. If the patient does not like it, then in order to bring this back into good functioning, we can use these two tools that we have.
Facial cupping and facial gua sha can also help to revitalize the facial expressions, and sometimes it’s not even just intervention. Sometimes there’s been injury, sometimes there’s been illness, sometimes just with normal aging, we can’t fully express in our faces the way we could perhaps before the illness or the injury, something like Bell’s palsy or a brain injury or a stroke or some trauma to the face, neck, or head.
This can all affect our ability to make facial expressions. Just using our regular acupuncture points and treating not just local points on the face, but treating points on the body and opening up, for example liver qi stagnation that may be happening across the forehead by opening up points on the body that help to open the smooth flow of blood and qi to the face can help with patient’s ability to fully express themselves.
And this is really the beauty of our medicine, is we don’t just look at the face as a series of muscles to be treated. We understand the connection between the body and the acupuncture points on the body, and the channels, and the different substances, and how keeping that smooth flow is really important in order to keep our facial expressions flowing smoothly and more fully.
So not just being able to smile, but being able to use all the muscles in order to smile fully. I hope that this short little lesson has helped to give you some insight as to how acupuncture treatments can work to treat the face, the facial muscles, and to really think about the connection between our expressions and our emotions.
And again, I would like to thank the American Acupuncture Council for this opportunity, and I look forward to seeing you next time.
I’m here to share with you over the next few minutes several challenges that you may be having, uh, in your claims in getting paid and getting paid as quickly as you should that may be related to your credentialing processes.
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.
Welcome, everyone, and thank you for joining me for a brief segment on credentialing components to your claims challenges. My name is Brandy Brimhall, and I am with Rapid Credentialing, and I’m here to share with you over the next few minutes several challenges that you may be having, uh, in your claims in getting paid and getting paid as quickly as you should that may be related to your credentialing processes.
It doesn’t matter if you are here joining me from a chiropractic practice, physical therapy, massage therapy, acupuncture, or an integrated facility. The information I’m going to share with you over the next few minutes could potentially help resolve some of your billing and collections challenges, your credentialing problems, and help you get paid faster.
So let’s go ahead and go to the slides, and I’ll jump in As we get started, again, we’re going to be covering, uh, at a high level the credentialing component to your claims processing challenges. So as we get started, what I’m actually going to share with you is sort of a high-level review of what those claims processing challenges are, and then as we conclude, I’m going to go through a bulleted list for you to really just help you hammer down what might relate to your practice and how to fix that, and really where to look to resolve those issues.
So really just covering a quick, uh, moment of really the foundation or the fundamentals. If you like to look at your business as sort of a brick-and-mortar, the three components that at least in my view make that up have to do with patient visits and patient care, rules and regulations, and so this isn’t just your state rules, but our compliance rules, our payer policy guidelines, and all of those things that help us to make sure that we’re getting paid properly in the best position to keep the money that we have been paid.
And then, of course, that other component is the revenue cycle system and all of the moving parts of that. We’re not going to be going through all of that today, of course, but the two components that we are going to be foc- focusing on in the topic that we’re discussing has to do both with the rules and regulations side and our revenue cycle system side.
So I’ve spent my career of almost 27 years now problem-solving with the revenue cycle system, and I’m going to share with you as it relates to a piece of the, of the com– the revenue cycle system and credentialing and enrollment that may well relate to you and again solve some of the problems you have.
So I first want to share with you really how enrollment and credentialing works. So first of all, what you want to know right out of the chutes is that if you’re enrolled and credentialed with a third-party payer, that doesn’t mean you’re credentialed and enrolled with all of the plans and products under that network.
That means you may have Medicare Advantage plans, Medicaid plans, other outlier plans under your contracted networks that you’re not in-network with. And so you may see claims coming in processing out-of-network for some payers where you believe that you are in-network with that payer. So again, you could be in-network with Aetna, for example, but out-of-network with some of their plans and products.
Enrollments, of course, must be maintained, and so once you’re co-contracted and enrolled with a third-party payer, that doesn’t mean you’re contracted and enrolled forever. Each of your enrollments are required to be maintained, and that means re-credentialed, attested, verified, and validated at a specific and set time period through your payer portals and with the payers directly.
If those verification or re-credentialing periods are missed, you well could lose access or enrollment status to some of the plans if not an entire contracted network Next, industry and network changes may require re-enrollment or re-credentialing. In other words, the payers as they sit today, in six months from now or a year from now, may have well likely added other plans and other products.
Maybe other payers have moved into your area or made changes. Maybe there’s been mergers with payers or departures of payer relationships and networks that impact how you’re credentialed and what steps you need to take in order to get credentialed or maintain your existing credentialing and enrollment.
So being aware of what’s taking a pl- taking place in the industry and certainly in your region can also impact your claims and collections and of course, your credentialing and enrollment status The next thing I want to share with you is contracting and enrollment is not the same process as your EDI and ERA enrollment.
This is another one of the questions I get across my desk all of the time is, “We’re contracted and we’re enrolled now with whatever third-party payer, so we can automatically bill.” You can bill, but you need to make sure that you’re first set up correctly in your clearing house so that you’re eligible to submit electronic claims and then ideally, of course, receive electronic remittance advice back.
So those are two distinct and separate pro- processes that often impact whether or not your claims are making it to the payer to be processed. Moving forward, I want to share with you how to confirm your enrollment with the plans and products, and so a few ways to confirm enrollment, and what I mean by that is you may be wondering now, “Okay, well, we are credentialed with Blue Cross of our state or Aetna or Cigna or whatever third-party payer, but how do I really know what list of plans and products my provider or our providers are enrolled with?”
There’s a couple of different ways to find that out, and I’m going to share with you now. The first one is you want to make sure that you’re utilizing any relevant payer portals, and so that could be ASH, Availity, Optum, and whatever of other portals may relate to the payers that you’re submitting. The other way to find out is to call provider credentialing to your third-party payers.
Understanding being one that does this on a regular basis, you may go through hold times, but once you’re able to get that information, it’s immensely helpful for your office at the front desk level, whoever is verifying benefits, certainly whoever is communicating payer expectations and coverage benefits and limitations to your patients, and then, of course, in billing as well.
It also helps you to know if there are other plans you need to be enrolled in or not. So you can contact your payers, again, through portals or by phone to confirm what’s called a plan list or a plan roster. Keep in mind, too, that these can change over time. If you were contracted recently or even many years ago, there’s an excellent chance some of the plans that are available now are, are either weren’t available at the time you enrolled or perhaps have been pulled from your existing enrollment because those plans are no longer in existence, and so networks do make changes that impact our clinics and our billing.
Everything to do with the revenue cycle system is imperfect. It’s always gonna be imperfect, and really, it’s an industry of constant change, and so it’s something we need to be aware of and know what to look for as we’re navigating our billing and revenue cycle system processes. So with that being said, you may find that you need to add plans and products to existing contracts.
At Rapid Credentialing, we call that adding lines of business, and we do a lot of enrollments to add different types of outlier plans or different, uh, categories of plans and products to existing provider enrollments, along with new enrollments as well, of course The proactive approach to credentialing and enrollment is always going to be your best approach.
Uh, payers will not generally grant retroactive effective dates, and so what you don’t want to do is find out months later that you’ve been out of network, didn’t know you were out of network, and had an opportunity sometime in the past to, uh, remedy that if that was what you really needed. So when you have questions, if you’re seeing claims not processing through as you would expect, make sure that you’re doing your due diligence to be proactive in peeling back those layers to determine why the claims are processing the way they are, and then obviously what next steps you might need to take in order to add those lines of business or those contracts to your provider or your business enrollments The next thing I want to share with you before we conclude is that EDI component.
So like I mentioned, this is a total distinct and separate process outside of the credentialing and enrollment and contracting process with your third-party payers. EDI stands for Electronic Data Interchange, and this is the communications pathway that you use through your clearinghouse in order to get claims to your third-party payers for processing.
If the EDI isn’t set up correctly, you’re going to find that your claims either aren’t making it to the third-party payer or perhaps are being misrouted to a different processing department than what you would expect, ultimately resulting in denials, claims being dumped, and you receiving nothing at all in return to know that action items need to be taken.
So make sure that you look at your clearinghouse, review your rejections and the reason codes and reason descriptions for those rejections to address those problems promptly. If you’re an out-of-network provider, it is still likely that you are required EDI setup, and so you may be thinking, “Well, I’m not contracted.
Does this matter to me?” It absolutely does, keeping in mind that some of our third-party payers don’t require EDI enrollment at this time, others do. So it’s definitely one of those areas you’re going to want to keep your fingers on the pulse of because there’s a lot of lost time and money in submitting claims and then forgetting about them and assuming they’re just gonna get to where they’re supposed to be, processed, and pay us back accordingly.
We all know it doesn’t always work like, like that, so you want to definitely make sure to keep your eyes on your EDI enrollments and, of course, all of the other related aspects of your clearinghouse. As we conclude, I’m joi– just going to leave you with a few of the common claims issues and some troubleshooting solutions that may resolve some of the claims processing and reimbursement challenges you’re having right now that could perha- perhaps be related to credentialing.
The first one is, we believe we’re in the network, but some of our claims are processing out of the network. Your troubleshooting for that is really going to be to confirm your payer or plan list, that plan roster that I mentioned, to confirm which plans you are really in the network with and which you’re out of the network with.
Again, you can always add those lines of business as it’s applicable Next, claims were previously processed in the network for one or more patients are now suddenly processing out of network. This could be because a missed attestation, cred-recredentialing or credentialing steps were needed to be taken that were certainly missed by the clinic or by a provider.
When that happens, you could certainly find that your claims, some of them for individual patients, aren’t processing the way that you would expect. You’d, of course, need to go back through the layers, make sure you’ve attested on your CAQH, your Availity, your Optum, whatever portals are related, and that you haven’t missed a specific recredentialing period that has ultimately caused termination to an entire network or some of the plans under that network Next, another example is provider is in-network with a local Blue Cross Blue Shield, uh, but an out-of-state plan is processing out-of-network.
So we believe the provider should be in-network because he’s in-network or she’s in-network with our state, but we have a patient from another state with another state Blue Cross, and those claims are processing out-of-network. This is another common one that comes across my desk, and really the way that it works with Blue Cross is there are many plans for in-network providers that cover all of the states if the provider’s in the network in their local region.
There are also state-specific or region-specific plans that are only eligible f- for in-network status with providers for providers in that specific region. So here again, if you’re seeing an out-of-state patient, it’s very possible their plan is not part of your provider’s network in another state. So you want to check that plan roster, make sure you’re verifying the appropriate set of benefits for that.
Next, we have a new provider that’s who, whose claims are rejecting at the clearing house or processing out-of-network. Couple of things to know and to look at, at on that, make sure that your provider is set up in the clearing house for proper claims submission. And then also, of course, make sure that your provider is properly credentialed, enrolled, and assigned to your business or your business group so that they are eligible to submit claims and your business is eligible for reimbursement for that new provider.
And finally, we have claims are being submitted and received, but they’re continually not, or they are appearing to not be processed, and there’s no remittance data that we’re receiving. This is typically through, uh, EDI, through your clearing house, and what you might find is that your claim perhaps could be being misrouted.
Payers will not often reroute claims to a separate processing department, even if it’s in w- within the same company. So you want to make sure that you’re verifying and setting up claims routing properly, because you won’t often receive a letter or a denial telling you that your claims are being rou- routed improperly.
Rather, you’ll often receive nothing at all and just assume that your claim is b- being received at the payer and never processing. So it could be an EDI setup issue, and that’s where you’d want to look and confirm, because keep in mind too, with every single payer we have, we’re on the clock just as soon as that patient, uh, is seen as far as timely filing goes with our third-party payer.
So we don’t want to wait too long and find that we’ve missed the opportunity to get paid at all And then next, the claims are rejecting at the clearing house, citing the provider is not eligible as a submitter. This is almost always related to the provider not being set up at all or not set up properly in your clearing house.
Those steps need to be taken. Once that’s confirmed, certainly you’d want to verify credentialing and enrollment contracts just to make sure that those are intact. Now, I know this has been a very high level and doesn’t cover all of the possibilities of how your credentialing could be related to some of your claims challenges, but I do think we’ve covered several of them.
If you have any questions at all, please feel free to reach out to myself and my team. You can see our contact information right there on the screen. Thank you so much for joining me. I hope this has been helpful, and I look forward to seeing you next time.