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Cash, Pre-Paid Packages, and Membership Plans

How do I make sure that I’m getting the revenue that I deserve?

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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.

Greetings to all my friends, to all our members, and of course, the profession of acupuncture. This is Sam Collins, the coding and billing expert for acupuncture, giving you a little bit more on this month about dealing with an office. How do I make sure that I’m getting the revenue that I deserve?

Because we have to remember what always is gonna be true, cash is king, and don’t move away from it. I’m not saying insurance is not viable, but there’s gotta be another place for it. Let’s go to the slides. Let’s talk about this. What about doing cash, prepaid packages, and membership plans? This is something a little different.

You’re all familiar with cash discounting and so forth. Let’s get a little bit deeper. Insurance coverage is growing. But unfortunately, people often face very high deductibles, limited benefits, and therefore, there’s still a lot of out-of-pocket costs. I’ve seen acupuncture policies where the patient has had a $75 copay.

They might as well pay your cash rate or maybe do something where you’re doing a membership. That’s something to take instance to. Okay, let’s talk about this. What is a membership plan? A membership plan’s gonna be a little bit different from the prepaid packages. Prepaid packages are still viable, and it is a way of doing larger discounts than the typical 5 to 15% pay at time of service.

But when you do a prepaid package, they’re buying generally a good number of visits. In doing so, what we run into often is patients wanting refunds or have other issues, or just committing to that long-term care. What about offering something else? This has been the way that you’ll see with a lot of these ca- I shouldn’t say chiropractic, but acupuncture groups, particularly modern acupuncture, has moved away from membership for…

excuse me, away from prepays towards membership. Why? Because it creates an easier access. Think, if you wanna create a value and a value add that someone is getting a good amount of service and thinking, “This is fair, and I’ve not prepaid thousands of dollars.” So here’s gonna be the rule, and this is gonna be generally across, All states.

I will say do verify if you’re a network member with me. Definitely get with me and say, “Hey, Sam, what about me and this particular state? Is there anything that I have to do differently?” For the most part, no. For the most part, it’s being transparent. However, let’s make sure. So in general, you may offer a membership plan.

It’s different than outside of insurance. It allows you to offer a membership for a fee that includes certain services that doesn’t become beholden to your regular fees when you bill insurance or pay on a single visit. There are real common ways of improving access to services where someone’s gonna have predictable healthcare costs.

Maybe you can say to them, “Hey, let’s deal with this chronic issue.” And what we do is a prepaid, if you will, membership monthly that will offer you two acupuncture visits or four, and maybe a therapy within that. That way it’s predictable. They know they can come in, they’re gonna set up, and I would have them set their appointments well in advance.

However, this plan has to be structured in a way that it’s showing that it’s not insurance and not gonna be based on any state issues. So membership plans generally should be limited to self-pay patients, meaning I’m not using any insurance, I’m just paying out of pocket, or if I have insurance, maybe it’s for an excluded service.

Now, this would be a typical for a regular Medicare Part B. This might be very attractive to them. Clearly state the services that are included, okay? Don’t just say it’s an acupuncture visit. What does that mean? Is that gonna be a 30-minute visit, an hour visit? Is it gonna include a certain number of sets?

Is it gonna include massage, cupping, Tuina, whatever the case may be. And I’m not saying no to any of those, just clearly outlay it. But make- be careful of overlaying that you’re gonna give a lot of extra things. I would make it an acupuncture visit, and then if they want additional things, maybe there’s a small fee for it.

Do explain, of course, there are cancellation rights. If the patient decides after a month they don’t wanna do it, no problem, just cancel, 30-day notice, okay? Here’s what’s good about these as opposed to a prepaid package. Prepaid packages require refunds of unused. A membership plan, you didn’t buy a visit, you bought a membership that includes something.

If they don’t come in that month, they just lost it, a gym membership in a way. Make it clear to them, though. So if you don’t come in for a month, those visits don’t roll over. Put that in the contract, otherwise they may think it will. At the same token, if they want more, they can buy maybe a bigger plan.

Key factor here is explain to the patient that it is a membership That if they don’t use it, that’s up to them, but it’s just a lost service they’ve gotten. Realize also we’ve got to make real clear it’s not insurance. It’s not a health plan. Doesn’t satisfy any health insurance for them thinking it’s got to be some type of insurance.

It is not. Indicate what services are included. Indicate what’s not. What are exclusions? What about cancellation? I would love for them to set up their appointments every month, have it set up already, and for the next month set it up again. Then if they cancel, as long as they reschedule, but what about cancellation if they don’t cancel within time?

Do they lose a visit, or will we roll it over for another week or two? Maybe. Make sure if they’re not using it and want a refund, you just refund the month. So it would be a 30-day notice, so it means the current month is good. It’s the next month you can cancel. And I love these ’cause they’re automatic renewal.

It could be something set aside. They have predictable amounts. “Hey, I’m gonna pay $59 a month.” Okay? What you want to be careful of is don’t promise unlimited services. Don’t just say it’s everything. There is no assumption of financial risk like an insurance plan, meaning you’re not assuming any risk.

You’re gonna just pay for two visits. And don’t represent it’s replacing insurance. It’s just another way of access. A lot of providers who are doing cash are moving towards this, and this is why you’re seeing the move in modern acupuncture and other plans of that nature that do this. By example, what if you said it’s $99 a month.

You get two acupuncture visits, and if you have additional visits, maybe they’ll discount them. It’s a month-to-month enrollment, cancellation any time before the next billing cycle. So before the next billing cycle starts, you can cancel. Once it’s started, then you’ve got that month, and then the next month we won’t be.

A clear statement, it’s membership. You’re buying access. It’s not insurance. Okay? And this is ge- this is generally more defensible because when you’ve sold a big package, and a person’s unhappy, and they’ve, spent thousands of dollars, and all of a sudden now they want their money back, sometimes I don’t want to pay it back.”

Generally, you’re gonna pay back what’s unused because they’ve actually bought visits. With this, they’ve bought access for up to two in a month, and that’s it. So if they don’t use them, no refund. If they want to continue for the next month, good, we continue. If they want to cancel. Okay? Do keep in mind, though, some states are gonna put a little more scrutiny, and this scrutiny really, I’ll say, is use it and think of it anywhere, consumer protection.

Be upfront of what your charges are. Okay? This is the cost. It can be something that the patient can say, “Okay, this is good.” There’s not gonna be something, they go, “I thought it was gonna be cheaper.” Lay it out. This is exactly what it costs. Avoid statements that it’s insurance. Define the services. Don’t make it like it’s whatever I want to do.

I know some of you for cash patients, one day you do an hour treatment, the next day you do 30, which I’m okay with. But then, of course, what if the person’s prepaid a package, and one visit you’re doing a 30-minute massage, some, Some gua sha and then cupping. The next time they come in, they might say I want that, too.

You wanna make sure for me it’s gonna be acupuncture.” And then the additional services may be added as necessary as long as they’re willing to pay for them, if you will. Be careful, long-term plans must have cancellation refunds. This because it’s not long-term, the cancellation is just 30-day notice. And then rights to refunds.

What the big thing here is you can see consumer protection. Think of it as you would want to be treated elsewhere. I like these. They’ve become popular because it’s easier for someone to commit to this. The difficulty is what if after a couple months they don’t like it? That’s up to us to create the value.

Make sure they set up for the appointments. ‘Cause when people come in, they feel better, but they get away like, “Oh, I should be going.” This is where you wanna start setting up, “Oh, we have a recall. Let’s get you set up to s- schedule maybe two or three months in advance.” Okay? Remember, for a contract, there’s gotta be cancellation provisions, refunds.

Refunds because it’s month to month shouldn’t be a big deal. Don’t mislead with advertising about something unlimited or that it’s insurance, and then make some clear expiration terms, which means 30-day notice. Okay? Excluded services, if you have insurance, become a problem because if you’re an in-network, like with ASH, ASH includes everything except massage.

So you could do an excluded service. So I’m generally gonna say stay away from this if you’re with an insurance, unless they have a service that’s excluded. Okay? That the insurance-covered services we bill, but this would be separate. I think it’s difficult to mix this. I’m not saying you can’t, but I would be- have some concerns with doing that.

Remember Medicare, I don’t see a problem. Regular Medicare Part B, there is really no direct access to you. These would be perfect patients for that. Medicare Part C patients may be a little bit different. With them, you wanna make sure they understand the parameters. And I’m gonna say certainly no for auto and workers’ comp.

Why would I do this for an auto and workers’ comp? That is a fee-for-service where they could be using that insurance. I just think this is another avenue for you. This is something we’re gonna go over in a lot of detail at our upcoming seminar at the end of this month. And if you’re a network member with me, you can reach out before then.

But let’s start doing some things to get proactive, to change how revenue streams come in our office. You don’t wanna have one funnel, but many. And it’s not limited to just paying cash at time of service. Bottom line, best practice, clear financial disclosures. What’s the plan? What’s the refund policy? If you resolve those, generally people are pretty happy.

People love going to acupuncturists. They feel better. Give them good access. As always, we’re here to help. Network members, get ahold of me. Get to our seminar end of the month. For those that aren’t, come and talk to us. This is something … We wanna make sure you’re successful. We have a vested interest in all of you.

The American Acupuncture Council is your advocate and always will be, and we’re here to support you. If you need help, come and see us. Until next time, my friends.

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Can Acupuncture Ease Osteoarthritis Pain?

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.

Can acupuncture ease osteoarthritis pain?

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.

What the evidence means in practice

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.

Evidence is strongest for the knee

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.

Practical implications for acupuncturists

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 theory and biomedical interpretation

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.

Benefits, limitations, and safety

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.

How to discuss acupuncture with osteoarthritis patients

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.

Conclusion

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.

Strengthen your risk-management procedures

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.

Review AAC informed-consent guidance

References

National Center for Complementary and Integrative Health. Osteoarthritis: In Depth.
National Center for Complementary and Integrative Health. Acupuncture: Effectiveness and Safety.
Kolasinski SL, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research. 2020.
Liu CY, et al. Clinical effect and contributing factors of acupuncture for knee osteoarthritis: a systematic review and meta-analysis. 2024. PubMed record.
Wang TQ, et al. Durable effects of acupuncture for knee osteoarthritis: a systematic review and meta-analysis. 2024. PubMed record.
Lee B, et al. The effect of sham acupuncture can differ depending on the points needled in knee osteoarthritis: a systematic review and network meta-analysis. 2024. PubMed record.

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.

Supporting Children and Adults in the Heat of Summer – Moshe Heller

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.

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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

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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?

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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.

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The Credentialing Component to Your Claims Processing Challenges

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.

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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.

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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.

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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.

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Why PI? Worth It or Not – Michael Coates

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Hi, I’m Michael Coates of Personal Injury Made Easy, and I’d like to thank the American Acupuncture Council for allowing me the honor of presenting to you on personal injury So this is part of a series on personal injury, but today’s topic, we’re gonna talk about why PI. We’re gonna talk about the pros and the cons, what providers that do really well in this kinda what, how they’re shaped, and other ones that don’t do so well, and we’ll also talk about some common myths.

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So the first thing I wanna hit to, into is about why personal injury, ’cause whether you should be in this or not, and I know that a lot of you have either experienced it in the past, and you may have had a very bad experience and a bad taste in your mouth, maybe from a law firm you dealt with or a particular patient.

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And I wanna try to have you rethink and have a new perspective. You also may be someone who has maybe dabbled in personal injury, just not done a lot. Maybe you’re a little frustrated, you feel overwhelmed or it’s out of your normal skill set. And the last would be the griddles, the grizzled veterans, those who have really have a, a solid personal injury segment, but I wanna make you better.

So let’s first talk about why PI or why to expand personal injury. So the first thing about personal injury that I think is maybe the best for the chiropractic and also the acupuncture base, and even for physical therapy, as I call them, the CAP providers, is about that you can bill your full out-of-network rates.

So when you think about a business and a practice, you also wanna think about your patient mix. Not all patients are profitable. Sometimes it takes a lot more patients to make the same amount of money as it does on a single patient, and that’s one of the beauties of personal injury, is that one PI patient, when you’re paid your 100% of your full out-of-network rates, can make up for a handful of in-network pers- or in-network patients, and also for a number of cash patients.

So that’s the first major benefit. The second one, which I find very valuable for your segment, is because it, you can bill for things that insurance would deny. So when health insurance wants to deny for laser procedures or the things that you really believe are medically necessary, are gonna help your patient, PI allows you to bill for it, and you’re gonna get paid for it, and that’s really significant.

The next area I would say is like what Warren Buffett said on investing. He always said, “Invest your money and your time and your resources by following the money.” So where is the money going in healthcare? It certainly isn’t going to normal healthcare reimbursements because healthcare reimbursements in the insurance industry have been cut in half, and a lot of medical costs have doubled.

But the one area you’re gonna find that there’s more investment in is personal injury. All you’ve gotta look is at the minimal auto policy benefits and the minimum insurance coverage in whatever state you’re in, and most of your states have had an increase or will be having an increase. So California, for example, went from 15,000 per each patient walking in the door to 30,000 behind them So that means it doubled, and a lot of states have gone way up.

So more money is being invested into personal injury to pay, of course, obviously it’s gotta pay the attorney, it’s gotta pay all of you, and it’s gotta pay the patient. But that’s a real benefit. But there’s more than just money when I say benefits or profits. So here are some other ones that I think are really fantastic for personal injury.

One is you’ve got no financial paperwork you really have to get on your patient because it’s the personal injury matter that would be satisfying your bill. So you’re really not having to chase patients. Now, sometimes you do, sometimes that occurs, but the primary aspect of PI is you’ve got an attorney who generally has a fiduciary duty to watch your financial back when they receive monies.

Even if their own client says, “Send me the doctor’s money,” wink, “I’ll pay him,” they’re not supposed to. In fact, if they do, it could be a violation of state ethics laws and other problems they’ve gotten into. So you have to hold it for you. So that’s a real benefit when you don’t have to chase patients and someone’s protecting your financial interest.

Also, it’s a great gateway to new patients. A lot of people have never heard of the magic of what you do. You know how good it is, but they’ve never experienced your medical specialty ever before. But you have the opportunity now here to wow them on how good it is, what you do, and what your profession is.

You get to educate that patient on the value, not just for them seeing you for PI, but for all the things you do. So that turns PI also into a great feeder to all of your practice segments. So that’s why I say when you’re growing a P- a PI practice, it’s not just growing personal- a personal injury segment, it’s using PI to grow all of your practice segments, and I think that’s a huge advantage.

So another really great advantage is medical, the medical lien area is a very collaborative one. So it’s not just you. There’s usually a healthcare team that is treating your patient. Now, usually because, let’s say you’re the chiropractor, you are the quarterback generally of that team. It is the only industry in this entire country where chiropractic is the number one lead medical specialty, just that one.

And for say for those in acupuncture, you’ve never even had that usually before, so it gives this whole new area to get into. But on chiropractic, being that healthcare team quarterback, you’re the one really guiding the referrals, and when you’re referring out or someone’s referring patients to you, it needs to be someone on lien, or if you’re in a letter of protection state, that will take it on LOP.

So that’s an advantage. In fact think of it this way. Every time you may have gotten a settlement notice from a law firm, and you’ve asked them to lay out all the settlement amounts, the attorney fees, costs, and all the lien holders, and the amount to their client that’s going, so you can make an evaluation of how much you should get paid, guess what you should be looking at?

the listing of all those medical lien holders. ‘Cause when you do, you now know in your community who is taking it on lien. It’s a great one to reach out to, to say, “Hey, let’s look about maybe collaborating.” But you’ve got to vet them first. Of course, you want really competent, good providers as part of your lien network, and you want to have that in the can, so when you do have to refer out to specialists, they’re there.

But what I’m getting to is that there’s a lot of peers that maybe doubt the efficacy of what you do, and they shouldn’t. It’s because just a lack of knowledge. So when you engage in the lien area, you have a chance to educate them also on how get it– good it is of what you do and how you do it, and you have someone else telling them, your patient Also their patient.

So that’s a great extra advantage. So there’s so many things that I think that are so pro– good about YPI, they outweigh the benefits. If we looked– outweigh the negatives. If we looked at the negatives, some of that’s gonna be obviously you have to wait to be paid, right? And it could be either months, it could be years.

Then again, going back to a positive, there is the fast cash options in personal injury. That would be MedPay, which most policies have, unless you’re in a no-fault state. For those states, you’ve got PIP, personal injury protection. Now, those are both auto policy benefits. They’re given for prompt care, they get prompt payment.

Now, attorneys do tricks and stuff, and we’ll talk about that later in the series. But in the end, it’s something really important to realize you can get paid on a monthly basis for you as a reha- rehabilitation professional, and that’s fantastic. You don’t have to wait. So you’ve got to learn how to identify when it exists.

You have to learn how to properly submit, and you have to learn when attorneys try to hijack it or maybe take fees out of it, how to address that so that doesn’t occur. So that’s fantastic, even though to offset the downer that I had. Now, of course, you are gonna be dealing also in an area that you get pushback.

Now, you don’t get people in insurance that are trying to sometimes degrade you or degrade what you do. It’s just the way that insurance tries to delay, deny, devalue, and defend. That’s what the attorneys do too, but they do it a lot more aggressively and forcefully. Why? They’re warriors.

They’re advocates. This is what they do for a living. Not just the attorneys, but a lot of the law firm staff. Back when I was first a defense attorney in my earlier years of course, everybody in law firms, whether on my side or the plaintiff side, all had law clerks and paralegals, so trained in the law.

They understood the law. That’s not today’s environment. All are– they are as a lien specialist is someone that follows a protocol the law firm sets, and they generally try to pay you less. But there are easy ways to work around that. You just have to learn. So that, again, is the beauty of this. And I think that personal injury’s just gotten this bad rap from prior bad taste in the mouth, like bad medicine going down, and it’s just from a lack of knowledge A lack of skill development and a lack of support for you.

Now, the great thing is all of you, you’ve got me to support you on whatever it is that you’re doing. So a little bit about me. I speak, teach, and coach around the country. I help providers in every state. All the state laws are generally unique in PI. I deal with really all medical specialties. And in the end, it’s trying to right the ship.

I think that medical providers have been used and abused, where first the attorneys are looking for themselves. They then try to make their clients happy enough so they will refer them or be happy and not slam them on Yelp. And so unfortunately, a lot of times they try to make the burden fall on you, the medical provider.

But that’s why I’m here, to help guide you along. And part of that guiding is this. When I say what is it that makes a good provider and a, maybe one who struggles more in this, and that’s learning how to be a value driver. What do I mean by a value driver? You al- are always to remain neutral as to the outcome of a PI case.

You’re there for the healthcare of your patient, and you’ve gotta stay in your lane. However, when you learn how to do personal injury right, you become a value driver to your patient, to your peers that you may be referring to or referring to you, and also to the law firms. That includes what are the things that could harm a PI case?

What are the things that when you put them in your documentation, it helps, as I call it, and we’ll talk again more later in the series, storytelling documentation, focusing on the ADLs, the DUDs, and the loss of earning. The other thing that, that’s so key when I talk about what works really great is when you can get across that value to an attorney early on in a case.

One of the biggest areas of tax that the law firms have to deal with for you, aside from poor documentation, and that is rampant in this area, I’m gonna make you better in this series. But one of the areas is of attack that the adjusters always do to the attorney, and it rolls downhill, is that you overtreat and overbill.

Now, usually you don’t hear about that till the case is already over. So a lot of times it’s a red flag. It’s not really the truth. But imagine this, if you could help the attorney support your fees and your billing before, when you’re first treating a patient, so that when they’re dealing with the adjuster, they cannot allow the adjuster to drop your bills, your fees, and lower them.

Because what does that do? That increases the value of every case. Because one of the, the tricks when I was, of course, being an insurance defense attorney is lower the value of the bills, lowers the settlement offer that we’ve gotta deal back and forth with them, and we save money, right? By you being, making yours more solid, you’re taking that kind of trick away, and it’s fantastic.

So that increases settlement value, and that’s just you holding firm to solid fees, but you gotta learn how to do that. And I do find there are providers that don’t do this area right, and they do improperly set fees too high. They have something different for personal injury versus other things. And in the end, realize you’ve got one fee schedule across, right?

We’ll talk about that more in process of the next one, but it’s really important to understand it. Okay, the, the other side of the coin is when you have proven the value, shown the value, they’ve gotten better results, obviously it makes it easier to get paid, right? From the good firms Even when you’ve got the good ones, I think you’ve got to realize that personal injury is an industry of pushback.

Insurance pushes back a little bit like, “Where’s the paperwork? You didn’t have the right code.” But in personal injury, the pushback is gonna be our client said they didn’t show these days or they didn’t get these treatments or you billed too high or your per office visit is way too high you’re way past Medicare, all these things they try to throw at you.

So in the end, what you want to realize is that those are tricks and traps and you got to learn how to spot them and then to address them. So those that learn how to do it well do really well. Those who don’t know what they’re doing get so overwhelmed and being the healer mindset that you have, you generally give in and I find it disappointing that a lot of you in your profession are so happy when you get paid half your bill.

Why is that? Are you not worth what you bill? If you are, I believe that in the cap side, chiropractors, acupuncture, and even physical therapy, that you should be getting paid 100% of your bill 80% of the time, or if you did a blended rate, because not all are winners, it’s at 80% for your medical specialty. So use that as a barometer, and there are– And it’s being done all the time.

So when the four-minute mile was broken, everybody else could do it. That’s what I’ve been doing in helping people in personal injury for medical providers. At the same time, they get more patients. So the other thing, our, maybe let’s address a few common myths. So some common myths out there in personal injury that I want to hit today are that MedPay is okay to be held by the attorney, and that’s not correct.

MedPay, as I was saying, has been for prompt payment. And what– The same thing is happening with PIP, by the way, which is less but still happening far too often than as what I see around the country. So when you get that, you have to first be able to identify it, and you want to make sure to make the proper professional pushback demands of attorneys to get paid back.

And remember I talked about an industry of professional pushback? They are being pushed back on by adjusters, defense attorneys, judges and juries even sometimes. So they’re not new to being pushed back. It’s how you push back. Do it professionally. And when you can learn about the facts that matter, have enough of the law to where you can be dangerous to know.

You’re not there to be an attorney, but once you can assert facts and law, that makes you also someone that the good attorneys want even more. And why? Because in the really good cases, they may go to trial. Less than 3% of cases actually go to a jury trial, but a lot of them position to that, and that’s where d- adjusters and defense attorneys say, “Do we settle or do we go forward to try?”

And the better that the expert is, the better that the treating physician is, the more likely we need to settle. So when you learn how to stand for your fees and your bills and can support it, when you’re treating properly, when you have the storytelling documentation when you then push back, the good firms say, “I want that doctor.”

That means they’re gonna hold up well at a deposition. They’re gonna hold up well at trial. They know what they’re doing So with that, we’re gonna wrap up for the t- today on this first session. I hope you learned a few things. You see a little bit of the overall, and the way to look at the rest of the series is this.

We’re gonna hit three segments. We’re g- And I think it’s three segments that build any medical practice, and that’s processes, systems, you know that well, but there’s unique systems in personal injury. The next is being properly paid, not just MedPay and PIP, but how to out-negotiate law firms, the trusted ones to get paid more, but also the really difficult ones, and how to protect your staff or for your staff to do it better.

And the last is growth. And like I said, it’s growing not just a personally injury segment, including how to be a better value driver, but it’s how to use PI to grow all your practice segments, and it’s gonna be fantastic for you because this really is the high-profit highway. That’s what personal injury is.

And with that said, I’d like to thank the American Acupuncture Council for their support in allowing me to present to you this wonderful series.

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How OBBBA Will Affect Patients and Reimbursement

what’s happening with what’s called the One Big Beautiful Bill So let’s go to the slides.

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Hey there. Greetings, friends and colleagues. This is Sam Collins, the coding and billing expert for chiropractic and acupuncture. We’re combining today a little bit because we’re gonna work talking about chiropractic and acupuncture combined on what’s going on or what you’re gonna be looking forward to, if you will, with what’s happening with what’s called the One Big Beautiful Bill So let’s go to the slides.

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Let’s talk about that to make sure everyone has a good understanding. The reason why I want to bring this up now is I’ve recently gotten a lot of questions from my network members and others asking, “Hey, Sam, how is this going to affect me?” And I wanna be- make sure that we’re being proactive and not reactive to what’s going on.

So what is this One Big Beautiful Bill Act? How’s it going to affect us? What makes a difference to us? Really what the One Big Beautiful Bill Act is, as related to healthcare providers, are the changes affecting healthcare insurance, if you will, whether it’s gonna be through Medicaid or through the exchange.

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So it’s more so gonna be an effect on the workflow that you have to do in tightening up are they insured or are they not. So the impact for providers is gonna be about insurance verification. This is really going to be mostly about people with marketplace plans. That’s the one they get through the marketplace.

Many people have them. And of course, anyone through Medicaid. Now, remember for California providers, we call that Medi-Cal, but it’s one in the same. It’s gonna really make a difference because, as you’ve probably noticed in the news, it’s gonna change eligibility. So it’s gonna require much more frequent verifications, and there’s gonna be some retroactive issues with it as well that someone may appear to be active, and then it’s taken away.

So here’s really what I wanna make sure. What if you say, “Hey, Sam, I don’t do a lot of Medicaid or none at all. I do mostly cash.” Then this doesn’t affect you at all. But if you’re dealing with people in the marketplace or Medicaid, it does. So most healthcare offices will have minimal effect unless you’re treating those types of patients.

So keep in mind, a lot of times when you’re hearing a lot of this hyperbole in messages, it often gets you panicked, thinking, “What do I need to do right now?” That’s why I say slow down and let’s look at it. Here it’s gonna be the Medicaid one. So it’s primarily on coverage, and let’s make sure too that I’ve seen some things about this that people say it’s gonna change how you bill.

It is not gonna change how you send a claim. It only impacts the coverage itself. So it’s not gonna impact coding or how claims are submitted, but primary coverage eligibility. So we’re gonna have to put a lot more pressure on us and the patient to what is or is not gonna be covered. This is really gonna begin next January, but I think it’s best to start getting used to now following through to make sure, does my system work through it?

Whether you’re using a Vality or something through your clearing house, you wanna have somewhere that can easily verify what’s going on with a patient because you’re gonna have to make sure that these people are still eligible. Why? There’s gonna be changes to eligibility. As you’ve probably heard in the news again, there’s gonna be eligibility changes based upon is the person able-bodied and working?

Are they doing volunteer service? So there’s gonna be a lot more verification. I think a lot of people will lose their plan, gain it back, and you’ll go back and forth, and it’s gonna make it very frustrating. So the bottom line is more patients may lose Medicaid eligibility during the course of care. I’m not even talking at the beginning, but during the course, you’re thinking, “Oh my God, what a hassle.”

This is why many of you say doggone it, that’s why I don’t take insurance.” In fact, I’ll let you in on a secret. In my dad’s practice when him and I were together, we took very little. In fact, my dad saw it as a charity. In fact, sometimes my dad would say, “It would be better to treat these pa- patients for free than all the administrative work,” which I’m not so sure he was wrong.

Bear in mind, though, some Medicaid plans for chiropractic and acupuncture can pay quite well, and in fact are the lifeblood of many practices. So we wanna make sure that you’re ready for that. More patients may lose their eligibility, so therefore eligibility verification has become important, done regularly.

I’ve had some people argue it should be done every visit, but I would say probably at least monthly or sooner because there may be changes that all of a sudden they’re saying it’s eligible now.” Two weeks later it no longer is. The risk of claim denials due to coverage termination is gonna be my big issue.

We wanna make sure that when someone comes in, as you’re well aware with the No Surprise Act and giving a good faith estimate, patients should be aware of what their charges are. So I think it’s gonna change how we as offices begin to make sure these patients understand if their insurance is not in effect, that’s not our fault We’ve done the best job we can to make sure that their coverage is there.

However, we’re warning them, “Your coverage may not be intact,” and as such, they would be personally liable. Therefore, they’re signing some type of financial agreement or otherwise to make sure that we’re not left holding the bag, because the truth is, I would rather not treat you and not get paid than treat you and not get paid.

So we’re gonna do a little bit more verifications, making sure it’s in line and patients understand their responsibility. So you’ve really got to conduct eligibility reviews more frequently. Now, they’re saying here generally every six months rather than annually. I would say maybe even quarterly for some, and some people may lose it retroactively.

So what may have been good through, say, March, all of a sudden for the next quarter is not. So retroactive Medicaid coverage will be reduced to one month, meaning that sometimes it could be as quick as one month it’ll be a turnaround. They used to have it where there’d be a three-month grace period. Now it’s only gonna be one month.

As a result, implement routine eligibility verifications. I’m gonna suggest if you’ve not already taken advantage of the electronic way through Availity or other systems, you really should. They’re minimal to no cost. In fact, Availity for the most part is free. But through other plans, there’s ways of getting that information.

Getting on the phone and calling, ineffective. You’ve really got to do it as an online part. If you’re a network member with me, reach out. We can go through what things you need to do. Bottom line is this: it’s not just Medicaid, though. It’s gonna be the marketplace or the exchange plans, and they impose stricter benefits on that.

I’ve just recently saw a lot of people have lost their benefits, so make sure, is it active? All we need to know when someone comes in, our job is to give you really good care. Insurance is their contract, and while we’re gonna do our best to make sure it’s covered, I want every patient understanding Our office has done the best job to verify your insurance.

However, we cannot guarantee coverage. You ever notice that when you contact an insurance, they always say this, “This is not a guarantee of coverage”? We’re gonna have to start doing the same thing. We’re not beholden to your insurance. If your insurance doesn’t cover, you have to understand your personal liability, and if they’re not ready to take personal liability, that’s fine, then we won’t accept them as patients.

Again, I go back to I’d rather not treat you and not get paid. So I wanna make sure there’s a good way of looking at this, saying, “Okay when is this policy effective? When’s the change date?” Because we have to make sure we’re gonna have potential issues where patients may experience more frequent coverage lapses.

They may lose coverage in the transition and have to be self-pay. Insurance card changes, plan changes. Here’s what the bottom line is. We’re gonna have to be more adept at verifications. It’s not as hard as you think. They’ve put so much stuff online to verify whether the person is eligible. Just plug in their ID number and you’ll see when is the effective date.

If we are proactive with that, I think we’ll run into far less problems. So really, what do you wanna start to do now? Now, just be aware. If you’re not doing much of this, I’m not really that concerned. You may say I may have a few people.” But bottom line is verify their eligibility regularly. Now, some will say before every visit.

I’m not sure I’m ready to go that far, but being if you’ve got an efficient system, that may work. Update financial policies. Make sure your patients understand their financial requirements in your office. Make sure you have a good, clear financial agreement. There’s nothing worse than someone coming saying, “Oh, everything is covered,” and when it’s not covered, they don’t wanna pay.

Remember, you’re not an attorney office. This is not one of these contingency things. If your insurance doesn’t pay, there’s no charge. Oh, no, that’s not how this works. Patients have to be understanding of their responsibility. Also, make sure you’re insu- obtaining their current insurance cards more frequently.

I would check quarterly, not just waiting for first of the year. Have you had any updates? Now, if someone’s coming in regularly, if there’s any updates, they probably make you aware. But if someone’s not been in a while, always say, “Hey, can we see your latest card?” Because a lot of times people get a new card, and they forget to tell you like, “Oh, I thought it was all the same.”

And strengthen your good faith estimate It’s very important patients understand their costs, just like we do. Don’t be afraid to be the office that we’re here to give you good care, but there’s an expectation of payment. And of course, if it’s not covered, could we put them into a self-pay plan, a prepaid plan, or even deal with a hardship?

Absolutely. But just be aware that this may change some coverages. Again, if you’re doing very little of it, may not affect you much. But realize we’re always here to help because you need to establish payment plans and coverage loss situations. What are we gonna do? If you don’t already work with me, as some of you are network members, work with me.

We’ll help you set that up. We already have some in- set up for you. Train your staff also, recognizing if they’re Medicaid eligible or they have marketplace, that has there been any recent changes? Has something changed with their job or whatever the case may be. Also, monitor your state Medicaid fees, because Medicaid fees in some states, really poor, but in other states, pretty good.

So this is something you’re gonna balance the type of practice you have, thinking of volume. It becomes more difficult if you are a type of practice that you spend a lot of time with patients, particularly in an acupuncture setting, there may not be as much value for you. So it’s something to consider whether or not is this a value to your practice or is it not.

The overall impact, it projects that it’s gonna indicate significant numbers of individuals that are currently covered under Medicaid or marketplace may lose coverage, so we wanna make them aware. But here’s the thing. As a chiropractic practice or an acupuncture practice, we are the most nimble at keeping things affordable.

Do you think most people can pay cash going into a medical practice? Absolutely not. What about coming to you? I think we do a good job as professionals at making things affordable, so don’t be afraid to put them into self-pay, prepaid, things where you can discount. My goodness, if you’re in California, you can offer a very large cash discount.

Know what your state allows. In Florida, you can do a prepaid monthly plan. So understand what your different states allow. Again, I would say reach out to me so we can make sure to set yourself up to make this be a benefit to your office, not something that’s a downer. Providers, the primary concern is not changes to coding and billing, but rather insurance patient coverage.

And if it’s not covered, put them into cash. Not a big deal. Eligibility verifications, financial responsibilities, make sure patients are clear. Just like when you go to purchase something, it’s the same thing. That part is the professional part. Make sure patients understand what they need. As always, we’re here to help.

If any of you have any concerns, reach out to me through H.J. Ross or American Acupuncture Council. If you’re a network member, we’re there to really help. We can do a one-on-one Zoom. Realize there’s some changes happening for documentation, very specifically for acupuncture. We’re having seminars this month, July 16th and the 23rd.

I hope to see you. But if not, keep a look for me online. We’re always here to help everyone. Best wishes.