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Are You Setting Yourself Up for an Audit?



Obviously, no one wants to be audited for anything. Let’s face it. No one wants to go to the I R S and be audited, but what I will say is, often the people who try to bring this up often do it in a way that they’re ultimately just trying to scare you..

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 there everyone. This is Sam Collins, the coding and billing expert for acupuncture for you and of course with the American Acupuncture Council. We’re gonna talk today a little bit about something. I know many of you hate to hear the word. In fact, it’s considered the a word audit. I’m in trouble.

What’s happening. Obviously, no one wants to be audited for anything. Let’s face it. No one wants to go to the I R S and be audited, but what I will say is, often the people who try to bring this up often do it in a way that they’re ultimately just trying to scare you and trying to elicit a response of fear so that you do something that they have like they’re the magic.

Clearly. I. Audits can be a problem, but I wanna talk about it from a standpoint. Is it really as much as people say, and are there some things that may make you more vulnerable, less vulnerable? Let’s get into that part of it. Obviously what occurs is many times an insurance company is simply looking at what you have billed and whether or not it was documented.

This doesn’t have to be insurance though. This is where people often have some misgivings. Quite frankly. If you’re doing a cash patient, there’s a complaint. They’re gonna look at your notes to see did what you say you did happen in the notes. And really, that’s all it comes down to. I’ve not really seen a lot of audits for their coming back for medical necessity, and I’ll never say that doesn’t happen.

But most often for Accu is, Hey, you build out something. Did you do it? And you have to think of what causes this? Why are they looking? I will tell you, in many instances, UnitedHealthcare recently seems to be the one that’s doing this the most, and I’m finding that often, to me, it appears they’re doing it because unfortunately, acupuncturists generically have some pretty poor documentation habits, and as a consequence, it’s low hanging fruit.

If they look at your notes. It’s not documented well, and I wanna make sure that we prevent that ’cause what triggers them to look at it, why? And often there’s these little triggers that happen. But let’s talk about it from this standpoint. Who protects you? You’re protecting yourself to start, but then you may have someone else behind you.

Like obviously I’m an expert and if you work with me in the network, I would wanna audit your notes myself to make sure they’re okay before even someone looked. But let’s talk about malpractice coverage. Obviously you all have malpractice coverage and the main reason you have it is just for that malpractice.

Frankly, there’s not a lot of malpractice, and I’m not saying it never happens, but it’s actually pretty rare. That’s why for the most part, your coverage is so low. But one of the things I want you to think of is do you have coverage for other than just malpractice by example, the most common thing I see an acupuncturist looked at for are gonna be either from the board.

Or it could be from an agency including an insurance on the documentation of your services that we call an audit. If you’re with American Acupuncture counsel for insurance, do you know it’s included up to $30,000 of defense, meaning they bring in attorneys of people to protect. You realize, invariably when I see an office audited and an insurance company has said that it’s not proper, most often it is.

Once we can work with it, or even if it isn’t, I wanna work with you to make sure, is it, and that’s how I’m gonna focus today, a little bit on that part of it, how to make sure that if you are audited, what do you need to do, but what things can trigger it. So let’s talk about the first thing that triggers someone to maybe want to look.

And frankly, it comes up when you bill something that’s unusual or out of the ordinary. In other words, if you’re floating in the middle of the stream, you’re okay. But if you get to the outsides, things can get a little bit trickier. Probably one of the big areas is your exam codes or evaluation and management codes.

What code are you choosing? Acupuncturists often will choose high level codes, which can be appropriate in many instances, but we wanna be careful if your style. Is to spend an hour with every new patient, meaning you’re billing a 9 9 2 0 5 every time. That’s a little unusual, and that’s not to say you wouldn’t have some, but to spend an hour with every patient seems a little bit odd.

Clearly, as an acupuncturist might you have a patient you spend more time with on average, simply because maybe they’ve been to two or three other providers, they have a long-term chronic condition. That history of evaluation may take longer, so certainly could be appropriate, but not everyone think of it simply.

If someone has chronic low back pain, surgical candidates been to a chio, a pt, medical doctrine, all of those things, I would bet that exam takes longer ’cause just the history of information they need to give you. Comparatively though, if someone has a hangnail, I wouldn’t expect that same type of exam.

So be conscientious. What triggers an audit or someone requesting records is when something is unusual. If you are billing a high level e and m code on a regular basis, you have a greater tendency for someone to look. Now, if you are doing that exam and can justified, I’m all in, but realize you become vulnerable.

So if you’re billing with that pattern, your documentation may be better in order. Because chances of someone looking at it means they wanna see and does it fit by example? Have you ever audited your own records? Like when you bill a 9 9 2 0 5, have you ever looked at the notes and said, do these notes meet that level of coding?

Did I have the medical decision making? Which is probably not, we don’t see things that severe Or do I have the time that justifies it? And often I found it doesn’t. So I want you to start to look and go, let’s make sure if I’m coding it, lemme make sure I know why. I’m picking that e and m code, and I would say that even applies with a 9 9 2 0 4 2 0 5.

The other place that runs into a problem is just the frequency of an exam by example. A lot of people come to me and say, Hey, Sam, how often should you bill for re-exams? And this is across the board. Really, even if you’re not an acupuncturist, a chiropractor, a medical doctor, is expected that re-exams are about every 30 days for recurring care of a patient’s condition.

If it’s sooner than 30 days, that’d be a little bit like why now? Could there be reasons for it being sooner than 30 days? Of course. What if you’re seeing someone for headaches and neck pain and then they come in on the next visit and say, Hey, last night I tried to list something. I twisted my low back, I felt a pop, and they have low back pain.

Sure an exam is appropriate ’cause it’s a new condition or new complaint. But if it’s to deal with the same area, chances are not until every 30 days. So be conscientious. What insurance companies do and what everyone does is just look at an algorithm. How often is something being billed and where do you fit with your peers?

If you fit outside the norm, someone’s gonna think we’re gonna take a look by example. Blue Cross sent out letters. Blue Cross Blue Shield sent out letters to many providers last year. On that factor about the frequency of the codes for E and s, but also the frequency of acupuncture. In the letter, it doesn’t say that you’re doing anything wrong, but it says your numbers are above the norm.

We want you to look to make sure it’s justified. To me, that’s a warning that an audit is impending. Now, I don’t care about an audit so long as we’ve documented and have the reasons, but I prefer not have to go through it. So high level e and m codes are just a very great frequency, is definitely one trigger.

So keep that in mind. If you have exams done every 30 days for ongoing care, you’re billing oh threes with an occasional oh 4 0 5, I think you’re gonna have no issue. The other area is just the sheer number of services you provide. Now for acupuncture, as I’m sure many of you are aware, you can bill up to three sets that are payable, and I haven’t found too much of an issue billing up to that number, however, Keep in mind if you bill everyone three sets, no matter what, that may be your style or technique, but be conscientious.

That shouldn’t. Some people have less or more. Now, I’ll never take away if that’s the style, but keep in mind when that number is higher, it’s gonna afford someone to look. Now, I do not care if you build three sets, two sets, whatever. Just make sure it’s documented. The problem I find is that many acupuncturists are never taught properly.

The documentation. And remember, documentation of Accu Acupuncture requires two things. You have to document the time. This is the time with the patient, and realize that time is soon as you walk in the room and say, Hey, Mrs. Jones, how are you feeling? That starts the time. It includes also tongue and pulse and evaluation, day to day-to-day, but also sterilizing your hands, preparing the points, choosing marking, inserting needles, all of those things.

So document that along with what points you have done. If you have that, we’re okay. Unfortunately, I’ve seen a lot of offices that don’t document that they may document one way off the other. So if you’re going to document acupuncture, remember it has two things, time and the points of each set, and they must be separate.

The time a person resting on needles without any active part to acupuncture does not count, but the active part of it and realize that takes a lot more time than people realize. It’s not just the point of inserting the needles. But all the things that lead up to, into, and the removal. So make sure that’s documented.

But again, if it’s more than three, so be it. There are, most plans won’t cover more than three, so if you do more, that’s fine. It doesn’t really matter. Just make sure what’s there is documented. The other trigger, of course, is just the sheer number of visits that the patient has. If you have a patient with an uncomplicated condition that you treat for a very long time.

The chances are someone’s gonna eventually look and go, is this care working? Why is this person continuing? Are they getting better or not? And again, it doesn’t mean it’s wrong, but they’re gonna start to question the efficacy. I would say start thinking of when you say someone has a stagnation or a chief stagnation, think of that as a functional deficit.

As they get better, the she improves, which means the function improves. And if we’re demonstrating that, I think medical necessity becomes a lot easier, but length of care can be a factor. But what about length of care? Depending on the condition, simple, low back pain, I would expect not to take too long.

But what about some of that’s had chronic recurring low back pain? That’s a little different. Maybe they have more complicated conditions. Maybe they have a disc injury. So there could be factors that are involved within that. So keep in mind, all I wanna make sure is that if anyone ever looks at your notes, they’re justified.

Let’s face it, people think all the time that’s only gonna happen with insurance. No, it doesn’t. If a patient makes a complaint to the board or has an issue, the board is always gonna want your records, and the board has certain standards that must be met regardless of insurance billing. So please be careful.

Don’t think because I’m billing cash or getting paid by cash, my documentation can be sloppy. No. You still have to have the same detail to indicate what services were provided. You can’t just do, I did acupuncture and it was $75. So give me a little bit more. The other factor is just number of services, and I’m talking generally, I talked a little bit about acupuncture, but what about additional services?

If you’re doing twin on gu sha cupping, those are all fine, but what if you have a person, you’re doing eight things on a visit? Does that not seem maybe just a little excessive? I’m not saying it absolutely is, but that would be unusual. Unusual things get looked at. Now, unusual on an occasional basis.

Everyone gets that unusual on a consistent basis means what’s going on in your office. That’s different. What I prefer to do is flow in the middle and when you get outside of it, if someone looks no big deal. One of the things I do with our network members when you join is I audit you. One of the requirements is I wanna see a sample of two or three claims from you, whether cash or otherwise to see are the things you billed for.

In the notes, because here’s what I found. I had an office once that had an audit, and the notes they requested, quite frankly weren’t very good. The insurance company was coming down on them, but because they’re with American Acupuncture Council Plus with me, we went back and said, yes, actually, we did an audit of this office six months prior and we found certain deficiencies and we have them correct them.

To include all the things they needed. Do you know they didn’t have to pay anything back in that audit because they showed there was compliance that, yeah, that older claim had that. But take a look at a newer claim where you can see that it was fully documented. Realize sometimes you’re just not doing things because you didn’t understand what was necessary.

If you show that correction can probably make all the difference in the world, and I see that happen way too often for you to not feel panicked oh my God, I’m gonna get in a lot of trouble. Most often, they’re just looking for you to be compliant. We see it with the VA and other plans, they just wanna make sure if they’re paying for something, that the person got it.

So if you’re doing a lot of services, great, document it, but also give me a reason why it can’t just be that’s what I do with everyone. No, it might be, that’s what I do with everyone with this particular condition. But not one that has a hangnail and a disc injury. You get my differences there. So thinking this way, don’t overly panic about an audit, but realize anytime anyone looks at your notes, they’re being audited, they’re looking, let’s make sure they’re in place.

So here’s some things that I wanna make sure that you’re doing. So let’s go to the slides, let’s talk about them so you can get a little visual of it as far as what’s happening. And you’re gonna look at what things are gonna trigger. So let’s get to the slides. I’m hoping my slide person is there to bring those up.

I’m not seeing them yet, but we’ll start there. I’ll wait for them to come in. But one of the triggers, as I mentioned, is gonna be high level evaluation and management codes. So keep in mind if you’re billing oh fours or oh fives, you have a greater chance of someone looking at you, which I do not care.

Just make sure they’re documented. So if you’re billing a 9 9 2 0 4. Or 2 0 5. What are the main things you’re gonna need to have? Remember exam codes are based on medical decision making or the time now medical decision making. I don’t think an acupuncturist is probably gonna see a condition that meets the medical decision making for a 9 9 2 0 5.

I’m not gonna say never, but very unlikely. ’cause you don’t see life or death things. However, what do you meet Time there could be a patient, let’s face it. That’s been to all these doctors that I mentioned. It could literally take a 45 minute interview plus an exam that takes an hour, so that certainly makes sense.

The same with the 2 0 4. Remember, that’s 45 to 59 minutes. Now, as an experienced acupuncturist, often once you’ve been around a while, do you really require that you spend an hour? I think in many instances, not don’t be overly concerned of, I don’t meet the medical decision making, but the time is there, which means document time.

Tell me how much time did you spend on this exam? If you’ve done that, you’re covered. Now be careful if you have an exam that you said you spent an hour and I see a half a page of information, I would go, how did that take an hour? That would seem unusual, but keep in mind, what if that person was hard of hearing?

There could be other factors, part of it. So high level e and m codes, and I’m hoping can someone go to the slides for me? The next factor is just simply evaluation and management frequency. Are you billing exams too frequently? I’ve had acupuncturists that mistakenly would bill an exam every visit. That is not appropriate an exam.

Every visit is not, it’s about every 30 days. So a lot of people think I can bill one ’cause I have to evaluate. Of course you do have to evaluate a patient each time, but the evaluation you do on a day-to-day visit is part of the acupuncture. . When you bill an e and m code or an exam, that’s when you do the big full thing.

So think of every 30 days. If it’s any sooner. Always do this check if I’m doing it than sooner than 30 days. Do I have the reasons behind it? In other words, do I have new condition, significant complaint, or change without that rethink and go why am I doing that? The next factor is greater than three sets of acupuncture.

I am all in and I have some acupuncturists that are mad and say people shouldn’t even do more than one set. I will never get into that argument. You do what you feel is necessary. Just bear in mind when you do more sets, someone’s gonna look and go, why is this always doing more sets? Nothing wrong with that.

But if you’re doing three sets of acupuncture, let’s remember what is the minimum you have to have documented? You must have 53 minutes of face-to-face time and no single set because there’s three is less than eight minutes. . So make sure the time matches and you have documentation of time and points for each set, and that’s the face-to-face time doing the acupuncture.

The other thing is just plain acupuncture documentation. Please take a moment to look at your notes and see that you have those two elements. That’s not really that hard. I wish the schools did a better job of teaching it, but this should just basically tell you from the start, always tell me time and the points.

If you have that, you’re fine. Where I think we run into a problem is people forget that and all you have to do is document it invariably, and I’ve been around acupuncture for 25 years as a patient, partly, but also as an expert on the coding and billing. And I invariably find acupuncturists generally will always tell us they see patients longer than the average provider.

I agree. I agree. I see that too. However, what do you need to do? Tell me the time. Tell me the points of each one. If you have those in place, we’re gonna be okay. And then just about therapies. If you are doing therapies in addition to acupuncture, I’m all in. But let’s be careful of not having eight or nine units of therapies.

Try to stick with four or less. If you’re doing three units of acupuncture, I would stick with maybe no more than one or two things that are therapies outside of it. Not to say never ever. But again, on a regular basis, we are not trying to do everything plus the kitchen sink. Keep it in mind. But if you’re doing more than that, what do you have to have documented the services?

If you’ve done more than four units or services, good documented. But if I did four units a time service, remember now my time has to equal 53 minutes. In addition to that, if I’m doing even more than that, I might have to as much as an hour and 15. Keep in mind, I had an offices a few weeks ago that they’re being questioned.

That they were billing for more times than their office was open. They were billing out, 20 hours of services and you’re thinking, how can you bill 20 hours of service in one day? For this office actually was quite simple. There was more than one acupuncturist working in the office. And part of it, they weren’t showing which acupuncturists were doing the care.

So they always thought it was just one when there actually were three acupuncturists. That makes sense, but it was looked at. Now, once they figured that out, they were fine. But remember, you can’t do more than one hour of acupuncture in one hour. So you can do four units, whether you’re gonna do four units on one patient or divided up among two or three or four depending.

So keep that in mind. And then just remember, always look at long-term care. If you’re doing long-term care, I get it. . But if it’s an uncomplicated condition, why? Realize there’s gonna be a point of, is the care really helpful? Now, I’m a believer in palliative care. I think it’s important, but let’s remember that isn’t always what an insurance will cover.

And this is where with insurance, it’s a bit different. If a person’s paying cash, you do palliative care all you want. Just make sure they’re aware of what it’s doing. So keep in mind here will be the point document. If you’re doing an , make sure it meets the amount of time or medical decision making, either one.

I think it’s probably more, mostly time. If you’re doing acupuncture, document the face-to-face time and the points of each set. Not a big deal. Not very hard. Once you learn that your life will be easy. In fact, I would say for acupuncturist, your documentation is quite easy, but it’s not something that you’re doing if you’ve never learned it in that way.

So time and points, and just make sure the care plan matches complexity. Simple pain or simple problems shouldn’t take as long, but things can take longer. But there’d be reasons behind it. And that’s not always documented or reflected in the diagnosis because often you’re limited to just the symptom.

But realize in the notes, don’t be afraid to include all of the complicating factors. Even the VA talks about this. What if you have a patient that’s diabetic, they’re very overweight, they’re very deconditioned. I don’t care what you’re treating ’em for. With those three things on board, it’s gonna take longer.

Even though you’re not treating the obesity, not treating the diabetes, it’s still gonna complicate it. Not to think that maybe some of those things might get better if they’re in less pain. Maybe they can be more active, lose a little weight, and all those things. But keep in mind, there’s reasoning. All I want from you is simply when you’ve billed it, make sure it’s there.

I’m your advocate. Make sure that if someone looks at your notes, they can see what you’ve done. It’s documented properly. No issue at all. I don’t care if you’re audited, just document the services. No one can ever come back and say you should have only done two sets. Who says you should do what you do?

Based upon your experience and expertise as a provider, you might wanna say, what do I ever get a chance to have that looked at? Our network service does that. I would say definitely take a look. That’s what we do. We offer you a way of looking at that beforehand, and it’s just part of the overall service.

I have a vested interest in you. . If you’re not successful, you wouldn’t need continuing education. Therefore, why would I exist? Your practice is not surviving. I’m not surviving. So we’re gonna be your advocate. The American Acupuncture Council is always gonna be your resource. Give us a call, make sure if you need help, we’re here to do that.

Until I see you next time, document. But take care of your patients and do well, my friends.


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Acupuncture and Therapies Sam Collins



And we’re gonna talk a little bit about reimbursements today in the sense of, let’s talk about the acupuncture scope of practice and more specifically therapies.

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 everyone. We’re back for another episode. Thank you for being with me. This is Sam Collins, your coding and billing expert for the American Acupuncture Council, specifically the network, your compliance, billing, coding, and most importantly, reimbursement expert. And we’re gonna talk a little bit about reimbursements today in the sense of, let’s talk about the acupuncture scope of practice and more specifically therapies.

Many of you are doing therapies, and I’m not saying you have to do therapies, but many of you do, and for the most part they are reimbursable. We wanna make sure when they are reimbursed that we don’t have any issues with that it wasn’t documented properly. Or some of these things some of you run into when you get denials because they look at your notes and go, wait, it wasn’t there.

I wanna make sure you know the quick and easy of how to do it, not complicated and whether or not who may provide them. As you’re familiar with physical therapists, chiropractors can use assistance. But can an acupuncturist. So let’s go to the slides. Let’s talk about what is the scope of practice for acupuncture.

So let’s look at the acupuncture scope of practice and look at what’s going on for us, what’s allowed, who may perform it, and all those things. I mentioned now generically, the scope of practice. Is one that it generally states this type of issue here, and I’ve just given an example. It means the stimulation of certain points or points on the surface of the body by the insertion of needles.

So in other words, inserting needles. That’s acupuncture. But beyond the acupuncture, of course, what else can you do for therapy? So you’ll see here it talks about, Generically perform the use of Asian massage, acupressure, breathing techniques, exercise, heat, cold magnets, nutrition, diet, nerves. In other words, much more than just.

Inserting needles. Now, this specifically is the California rule. Let’s look at another one here. Let’s take a look at Massachusetts, cuz sometimes these rules are somewhat vague or very specific. I’m gonna say, please know your state regulations because some states have more generous allowance, some have less.

So here’s Massachusetts. It talks about adjunctive therapy, so that means things beyond the acupuncture. But notice what it says shall include. But not be limited to. And whenever you say it shall include, it means these things. But of course, more. And I would say pretty much everything you learn or are taught in a standard acupuncture curriculum.

So this is gonna include lots of things in therapies, but also things like what they stayed here for Massachusetts, nutritional counseling, herbology. Recommendation of breathing techniques and exercises and lifestyle, behavioral supportive and educational, and even stress counseling. I wanna focus in on are those things billable?

That gives a pretty broad notion of could they do massage? Sure. That would be something that would be a. Not limited to. Then we’ve got someplace like Florida, which really lays out a ton of things, and I bolded it here. Notice Florida says manual stimulation, accument even goes so far to talk about massage, acupressure, shsu, even tuna.

Electric stem laser, and then even goes into the details of what type of Oriental massage you may have notice here it talks about acupressure, amma ammo, gua rah, reiki, and so forth. Again, given the details, so again, you can see this is a very broad scope. They can do many things. However, let’s take a look at New York.

Some states are more restrictive. It says, the profession of acupuncture is treating by means of mechanical, thermal, or electrical stimulation affected by the insertions of needles or by the application of heat pressure or stimulation at a point or combination of points on the surface of the body. Now you notice here the much more restriction, it doesn’t give adjunctive therapies.

It specifically says heat pressure and electric stem. It doesn’t talk about exercise. Massage or manual therapy. So you wanna be a little bit more careful now as restricted as you will as New York can be. New Jersey across the border, it’s gonna have the most generous, I’m just pointing out, please know what you can provide within your scope.

I’m gonna take the generic standpoint of, for the most part, acupuncturists can perform standard physical medicine services, physical therapy, and so that’s gonna be this listing here. If you’ve ever attended a seminar with me, you’ve seen this type of list where I give you the common C P T codes. You’ll notice that we include acupuncture, of course.

That’s something you can do by nature. Can an acupuncturist all do also do needling? Oh, of course, if you’d like to. Never the same time, but you could. I would recommend acupuncture, of course, but it includes also doing modalities such as heat or electric stem, but also constant attendance ones. What about electric stem?

That’s manual. How about even laser? Notice there’s two different codes for laser. And then of course we have the other things like exercise, massage, manual therapy, even therapeutic activities. And a lot of these, sometimes people are going what do these all mean? What are they? And so I like to think of it, not so much as trying to reinvent and trying to teach you something new, but let’s talk about the things that are commonly done in an acupuncture practice.

What are common therapies? Of course, heat, I would say majority of acupunctures I’ve ever met use some form of heat, whether it’s infrared. TVP lamp. I’ve seen hot stones, hot packs, but heat almost always in scene within scope everywhere, but would also include things like electric stem. Now, I’m not talking electric stem of the acupuncture.

I’m talking electric stem generically, like on the surface, like a TENS unit or the little pads people apply. That’s not uncommon. But it also includes all types of body work, meaning massage or manual therapy or just soft tissue manipulation. I put it generically, this could include twink. Even Gua to an extent, we have to look at word of those fit, but it also includes, and this is something that I think acupuncturists often forget, the active therapies like exercise.

These three codes are in fact covered under the VA program, which are gonna be just standard exercise, therapeutic activities, more functional, and then even balance or coordination training with neuromuscular education. I’m gonna say these are probably the four or five things that are pretty common now with, on that, I would say also cupping in moxa.

Outside of the va, though, we don’t find commonly cupping and moxa will be paid, though I’m not saying not to do it, not to bill a patient. And or the insurance. What I can only guarantee is it’s payment under the va. But nonetheless, these are the common ones. Now, you might say Sam, I’m doing a few more.

That’s okay. If it’s within scope, I’m all in, but I wanna talk about the common things to make sure, are we documenting it properly? So let’s talk modalities, things that you can apply to a patient. But you don’t have to be there. Like you can turn on an infrared heat lamp or a TDP lamp. Let the patient relax, let that heat do its work, but you don’t have to stand there while they’re doing it.

So we say those are unattended, which means there’s no time. So you either do it or you don’t, and you bill accordingly. But we still have to make sure how we’re documenting. And the same would apply. What if you’re doing a modality that is timed? So what does documentation need? Infrared heat. It’s as simple as saying you applied infrared heat to the lumbar spine or whatever, the body region.

Now you’ll notice here I put 15 minutes. Is 15 minutes required? No, because it’s a modality that’s unattended. I’m putting 15 minutes so that I know in my notes how much did I do last time. What I’m pointing out though is that the time that you do it is not going to change how much you can bill. It’s one unit only.

Nonetheless, the key factor here is indicating where I had a provider. And this is with United and a few others that got denied for infrared heat because when they reviewed their notes, it didn’t indicate where. Now the provider said Sam, I was diagnosing the patient’s low back, so obviously the heat had to go to the low back.

I don’t think that’s an illogical explanation, but it doesn’t fly. Always make sure to simply tell me what type of heat where’d you do it. In addition, what if you are doing electric stem? Tell me what type are you doing? Two pads, four pads. What’s the intensity? In fact, the easiest way to think of this should be documented in a way that any person reading it would know how to apply it.

If I told someone, put a hot lamp on their low back for 15 minutes, would you be able to repeat that? I don’t think too much trouble or if I said electric stim in this manner. So think of documenting as just a way of highlighting what you’ve done, not by checking a box. Checking a box that says I did heat would not be sufficient because where did I do it?

What type of heat and so forth. And that even gets more confusing when you look at some of the hands on stuff like massage versus manual therapy. What is the difference? They’re very similar. Generally manual therapy is more focal, I’m going to say probably I. Deep tissue, if you will, that’s focused on a trigger point is probably gonna fit more manual therapy, whereas the more generic stroking and relaxation would be massage.

The key factor is document what you’re doing with either one to differentiate between the two. So tell me what type of massage you’re doing, or trigger point or myofascial release. Lots of ways of describing it. Tell me how much time you spent, because this is a time code now you can put start and stop times.

You can say I started at 11, ended at 1135. Or you can say I did 35 minutes. Either way is acceptable, but it is absolutely required that you put how much time, like acupuncture, you have to have the time element. So simply document what you’re doing in a way that when someone looks at it, they can see what was done.

And then of course, always have a little bit of, why’d I do it? What was my purpose? What was the outcome or the goals? Give a little bit of how the patient felt after the visit. Did it accomplish what you’re looking for? Even exercise acupuncturist, if you think of probably, The most ancient form, if you will, probably stems back to acupuncture.

When you think of Chiang Tai Chi and those types, the enhancement of the physical culture of the body. Now, that doesn’t mean you’re turning your office into Gold’s Gym, but what if you are doing some exercises or you’re putting the patient through a series of stretches or other types of exercise, yoga.

Otherwise, absolutely. Just tell me what you’re doing. How many sets, how many reps, or whatever the amount of time that you’re spending. The key factor is when you’re documenting anything that’s time. Do remember the eight minute rule. This is the same. That’s true for of course, acupuncture. Remember, one unit can be as little as eight minutes.

That’s perfectly fine for one unit, but to get to two units, it has to equal 23. So let’s say by example, you did 10 minutes face to face for acupuncture and 10 minutes of exercise. Would that be acceptable to bill two units, meaning one of each? The answer is actually no, because if you think of it, if I did 10 minutes and 10 minutes, what’s the total number of minutes?

Only 20. Therefore, that’s not enough for two units. Notice two units takes 23, so it’s 15, if you will, plus eight to the next, so you gotta make sure it adds up. Now, by contrast, if you did 11 minutes of acupuncture face-to-face, and then 12 minutes of exercise. That actually would count. It’s that specific.

Tell me the time. Generally, when you write the time down and you really put from, and two, you’re gonna find, you probably have spent more time than you realized. If you just simply wrote, you spent 15 minutes, you may or may not have spent 15 minutes, often spent more. Keep in mind, look here on what is acceptable for documenting time, though don’t make this hard.

There’s two ways to do it. Tell me how many minutes I’m right here. Or just tell me from, and two, from nine 30 to 9 45. I’m okay with either, but get it in there. What’s unacceptable notice are the generic things like just putting down that I did a unit or telling me that I did an average time. I saw someone said I spent 25 to 35 minutes.

Huh? Either you spent 25 or some number up to 35, but not between that. So just be specific and then please don’t fall to where you just say, I did two sets or two units. It’s gotta be time. That’s not very hard at all. In fact, I think if we were taught that initially in school, probably be a lot easier for many of you.

But just think along those ways. Tell me how much time you spent. I am invariably fine when I help to audit and deal with these types of issues when I talk to the doctor. It turns out they often spend a lot more time than they’ve documented simply because they try to average. It’s what I call, if you tell someone, oh yeah, it takes five minutes to get there.

Does it ever actually take five minutes? Maybe not. That’s the idea. Once you get on the freeway, tell me how much real time it takes, and then let’s follow with, can I use an assistant to perform these? Now as an acupuncture, can you do these clearly part of scope, part of the services.

In fact, the VA encourages it, but may you use an assistant. The answer is no. There’s no laws that create acupuncture assistance in the way that can do therapies under your supervision, meaning that you bill for it. If you are billing for it, you have to provide it. Now by chance, if you had another acupuncturist working for you that did it, then I would say yes, but not someone that’s not licensed under you, if you will.

So keep in mind, we’re not there yet. I’m hearing rumors of some states and I’m hearing maybe Arizona’s gonna be the first one, but as of now, you would need to do all the services that you bill for. You cannot have. A staff person. Now, I know there’s some states that allow people to pull needles, things of that nature.

But again, keep in mind as far as the therapy, no assistance. Now, I’m hoping we get a change there. Obviously chiropractors use them, physical therapists use them. I would think acupuncture should also, but until we have the law, I’m going to say no. Let’s not make this hard. The main thing you do is acupuncture, but there may be therapies that are adjunctive.

Make sure they’re in your scope of practice. Make sure they’re documented. And your dog on you’re gonna bill for it. That is money you deserve and should be paid if you’re not billing for it. If someone’s willing to pay you an extra 50, but you don’t bill for it, they’re not gonna pay it. That’s what I do for you, is to make sure that we can help you get paid.

That’s why we do these programs. It’s what we’re doing for you. If you want some real day-to-day help some that can really make sure you understand what fees should I have, how do I document it properly? Can you help me office, Sam, make sure it’s okay. My job is to always make sure that you honestly just have a better business.

Meaning one that is compliant, but one that also makes sure that you’re getting maximum reimbursement. Give us a look at our website. Otherwise, I’m gonna say it all you. Thanks for being with me. I’ll see you next time. And until then, continue to take good care of your patients.

See you next time.


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Get Claims Paid The 1st Time You Submit Them



But let’s talk about making sure that when you are dealing with insurance or dealing with claims that you’re not getting these common errors and common denials that are so frustrating because we wanna make your life a little simpler.

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 everyone. This is Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council, and you the profession. As always, we’re trying to make sure your claims are getting paid. You can make your life a little simpler and more profitable. and you can do what you like to do, which is care for patients.

But let’s talk about making sure that when you are dealing with insurance or dealing with claims that you’re not getting these common errors and common denials that are so frustrating because we wanna make your life a little simpler. Again. I want you to be able to treat patients. Let us take care of the billing part.

Let’s go to the slides. Does that talk about common denials and how to correct them? What goes on for acupunc? Why do claims get denied? What are some of the common things that we see? The most common thing that I run into, and I deal a lot with this, I lecture every year to thousands of you, many of you’re members of our network service, and one of the issues we run into, you’ll get a denial that says, The plan is not covered and you think I did the verification.

How is this not covered? What happened? One thing I want to really implore you to do is make sure you understand the coverage the patient has. Often you will see coverage that will say, we cover acupuncture, and you think, great, you’ve verified it. They cover acupuncture. Then you send a claim and it comes back denied.

What do you do? First I’d look to make sure was it really covered or ask this question. If there’s coverage for acupuncture, must the provider be in network? A lot of plans do have acupuncture benefits, but only for providers who are in their network. So don’t be confused. Often you’ll call and hear all these great answers like, is acupuncture covered?

And when they say Yes, you hang up, or you hang up and say, great, that’s phenomenal. Then you send a claimant, it’s not paid. It’s because you didn’t ask that other. is the coverage for in or out of network providers. And then I would further ask this question, do you see my office as in-network or. , if you’re out of network, is there no benefits?

So let’s often make sure that the plan, you know what it’s covering. Also know the types of coverage that it has. What does it cover in the sense, does it cover acupuncture alone? Does it cover therapies? If you do therapies? So be careful. That is a common area of denial. Make sure you verify the coverage.

The other area that we run into lots of problems with are claim forms. We’ll get into those specifically, but how to fill it out. None of it is very. But there’s a couple unique things. If you don’t do correctly, will commonly come back and it’s very frustrating. What about just improper diagnosis?

That’s certainly an area improper use of A C P T code, if you will, but also just missing a modifier and you’re gonna wonder what modifiers do I need to do? Don’t give you a quick primer on that today to make sure we’ve got the right information, but also make sure you don’t run into the one where it says insufficient document.

Is, do I have enough information to make sure the claim gets paid well? Let’s talk about claim forms. What are some of the common things that I run into that offices have? When someone comes in, they’re gonna present an insurance card, and on that insurance card we’ll have their information for the claim.

That’s what goes to the top part of this claim. Whether or not it’s a standard or group health insurance plan, or maybe it could be Medicare under some circumstances, but nonetheless, check that off properly. But the bigger issue. Do I have the patient’s name proper? Please note it says here, patient’s name, last name, first name, middle initial, whatever it is, make sure it’s exactly as appears on the insurance card.

So often I’ll see denials because the patient will have a name that they’ll say, oh, just call me Patty. When on the card it says, Patricia, don’t put nicknames. Also, make sure you’re putting the exact insurance ID number. We will often see numbers transposed. Because it just goes in and makes a quick error.

So do make sure now, once we’ve got that set, that ends it, but it’s nothing more frustrating going, wait a. , what information do I have to have? And this is often concerned. Many times it’s gonna be the patient and you’ll indicate self, but what if it’s the spouse or the child? Often you’ll put the patient’s name here, but if the name is different on the car because maybe it’s a child or it’s the spouse’s plan, remember their information goes here as the insured’s id.

so be careful. Sometimes the patient may be different from the insured, though they’re both insured. It depends whose name is on the card. So don’t run into that common era. But here’s a big one that comes up quite a bit. What about block 14? When you’re filling out the 1500 form and block 14, it says, date of current illness.

And so many people look at that and say what does that mean? What do we put in? Were you gonna put the date generally of when the patient had the first symptom and or an injury? But often you might say This patient had an injury or this pain has been there for years. Obviously if I put something 20 years ago, they’re thinking why are you putting that date down if it’s a very old date, or it’s a type of a chronic condition that continuously flares up?

Always update this date to the date where the patient presents to the office. So it doesn’t always necessarily have to be a date of injury. It could be the date of the first visit, but do make sure it’s completed and put in this area. And one quick note, if you’re billing Anthem, Anthem is a little bit weird.

Anthem wants the date of the first symptom here, but they also want to block 15 the date of the first visit. So this could be a week ago, and this is today’s date because it’s the first visit. And then the qualifier you’re gonna put there is 4 54. I know a little bit odd, but 4 54, that’s gonna be Anthem policies.

Anthem policies seem to require that a little bit more than anyone else. Now, again, just Anthem. Now the other area that I commonly see, and this is really a big issue for acupuncturists, is not having a complete code. Do make sure if you’re using coding, make sure that code is complete. Often you might be using a code that’s a little bit old.

Remember, codes do update. Some codes are three digits, some could be as many as seven. So please make sure if you’re using any coding, assure your codes are correct with a number of digits. Notice this one for just pain. R 52 is just three characters, yet this sprained strain. Is all the way up to seven characters, so do make sure it’s the proper one.

But here’s one to keep in mind though. , it’s more important to know what codes are gonna be payable for acupuncture, and this is where things get tricky. Last time I did this class with you, we talked about specifically certain types of insurances, specifically Aetna, on what they cover. Let’s look at a few other ones.

Here’s the company, American Specialty Health, and as you’re aware, well aware, they manage a lot of particular companies, particularly Cigna, some of the Blues, some Aetna plans as well. And they use what I call , I don’t know, physical therapy or chiropractic end of coating for acupuncture in that they want the neuromuscular skeletal type pain things.

Notice the things that they cover, headaches, hip or knee pain with osteoarthritis, extremity pain with or without osteo osteoarthritis or mechanical irritation, and just other syndromes related to the joints in muscles back and neck pain. So you’ll notice that’s not including like abdominal pain in other internal symptoms.

It’s really musculo s. Except for nausea and vomiting. So no, for this plan, if you were to code abdominal pain, not gonna cover, but if you code low back pain, it will. Now also, keep in mind, some things could be tricky. If you’re ever dealing with a Medicare advantage plan, common denials are because you’re using the code thinking, oh, I need low back pain and put M 54 50, when in fact, for the Medicare plans, whether it’s Medicare, part B, or.

You have to have M 54 51 or M 54 59, so it’s good to understand the nuances of what’s covered. Here’s an example of a course, the one we went through last time, which is the Aetna plans. These are the codes they cover, which tells me if you bill these codes, they’re gonna pay you. Bill something not on the list, they’re not gonna pay you.

So it’s important to start to learn the nuances of what codes are covered or not covered. That’s one of the things that we cover in our seminars. Or more importantly, if we do one-on-one as a network member, I can go over with you. Here’s what Health Partners has, here’s what UnitedHealthcare has, cuz it’s important to know what codes are payable.

Nothing’s more frustrating thinking something is. and it comes back not covered all because you didn’t understand the codes that they require. Another area that commonly comes back is that hey, I build for four sets of acupuncture. . They only paid me for three. What’s going on? Or sometimes, maybe they paid me for one, depending on the plan.

Under the standard rules, and this is across the nation if you will, there’s something called the medically unlikely edits. And what, these are the maximum number of services that are payable per a visit, and this includes all types of chiropractors, physical therapists, and so forth in every code or service.

Has a maximum number of services or units that they will allow. In this case, for acupuncture, it is three. They allow up to three. So if you bill more than three, they’re not going to pay it. They’re simply gonna bundle it. So do keep in mind it’s three, I’m sure you’ve seen as if you’ve ever dealt with the va, Cigna, United, and many of them.

Now, are there some plans that may be. Sure I’m familiar with plans out of New York, particularly New York ship that will generally pay up to four. So I’m certainly gonna say, bill, what you do, but do understand some plans will max out at three. So that denial is simply one of just fruition. They just don’t allow any more than that.

So again, if you’re billing more than three, that could be an issue. The other issue for acupuncture though, Modifiers and denials. So you notice here’s a claim form someone with simple back pain. But notice there’s the acupuncture codes billed, but then notice there’s modifier 25 on the exam. This is probably the most common denial I get for acupuncturists, is Sam, they didn’t pay for my exam.

The first thing I’ll ask you is, did you bill with modifier 25? And most of the time the acupuncturist will say to me what do you mean by modifier 20? As soon as they say that I know the reason. Remember, anytime you bill an. With your treatment, any treatment, you have to put modifier 25 on the exam code because this demonstrates that this exam is above and beyond the day-to-day evaluation.

In fact, what it means is what’s printed in bold here, if and only if the patient’s condition requires a significant separately identifiable e and m service above and. The pre-service and post-service associated with treatment. Remember, acupuncture or treatment includes a little bit of an evaluation, so every day there is evaluation.

It’s small, but there is, Hey, how are you feeling today? Is it better? Is it worse? Maybe you’re doing some palpatory findings, tongue and pulse. That small exam is embedded into. the acupuncture code, and that is the reason we put modifier 25 is cuz what we’re stating is this exam is above and beyond what we do on a normal day to day.

and therefore is payable no 25 no money. So make sure it’s there. Now what about a plan that doesn’t cover an exam? That might be a bit unusual, but it depends on your contract. What if you’re contracted with a company like a UnitedHealthcare under Optum, where they pay you per diem? They don’t pay separately for exams because they bundle it all as one payment.

So do keep in. That sometimes it’s a contract issue, but other times it’s just the fact, did I have the proper modifier? Now, you’ll notice none of these other codes have any modifiers on it because it’s not needed. However, what about this last 1, 97, 1 40? I know some of you’ll say I wanna put modifier 59, truthfully, a modifier 59 to indicate a separate services never needed.

However, you will need for some. Modifier gp. Now, this is why I think sometimes acupunctures go, I don’t know if I wanna do insurance at all. It’s just too much hassle. It really isn’t. It’s just understanding the nuances of it. Once you understand it, it’s not hard. So now here’s the rule. If you’re billing United Healthcare, You’re gonna put a gp, G as in George, P as in Paul at the end of a physical medicine code.

So that’s all physical medicine codes, whether it’s from heat all the way through the unlisted service, but massage, manual therapy, you name it. And it’s gonna go on all of these payers, UnitedHealthcare, that includes Optum Health and everything affiliated U M R U P M R, VA claims will. Anthem requires it.

And if you’re in California, here’s a weird one. Blue Cross of California, not Blue Shield. And of course, any of the Medicare plans or federal plans you may do. So again, think of it, a denial will come back and you’re thinking, why didn’t they pay for a therapy? is because you were missing the modifier when it’s one of these policies.

So do keep in mind, focus in on making sure that I have the claim form right, and that’s one of the things I help with. That’s why I’m an expert. I’m here to help you to make sure that you do well and that’s what these short courses are for. Now, one thing to keep in mind, you’re thinking if I’m gonna put a GP.

I’m just gonna put a GP for everybody. Nope, do not blanket it. Don’t include it for plans that don’t require it. Only the ones that I’m showing here. And here’s the final thing I’ll get into is that it’s just INS insufficient information. And you’ll notice here it says, according to 9 7814, it’s not supported.

The medical records submitted do not indicate the needles were inserted and does not indicate the face-to-face time. Now this is something for another course, but do keep in mind if they look at your. Can they tell what you’ve done? Now, here’s something interesting about this claim. You’ll notice the initial set is paid.

They’re saying it was supported, it was the follow-up set. So you gotta start to look at your notes and go, wait a minute, do my notes demonstrate what I need? Do I have the face-to-face time? Does it meet the minimum standards for each individual set? So that includes first set in multiple sets. And again, we need the time face to.

As well as the points of insertion. None of this is hard. Let’s face it, it can seem daunting if you’ve never done it. Once you get a good feel for it, you’re gonna go, wow, that’s really easy. I want you to think of, you sometimes will say, I don’t think I want to take insurance, cuz there’s these hassles. Do you realize the majority of people have insurance and they have acupuncture coverage?

Don’t you think they’re gonna want to use it? I want to give them access. What I have to do is make it simple. That’s what we’re here to. That’s what these courses are for. And that’s it. If you wanna really get some one-on-one help where we work together, we zoom directly one-on-one. You can even go to our seminars for free.

Take a look at the American Acupuncture Council Network. We’re here to support you. Your success is ours. Until next time, my friends.


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Aetna’s Mandatory Acupuncture Benefits



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.

Hey, greetings all, it’s Sam Collins. You’re coding and billing expert for acupuncture in the American Acupuncture Council. Most importantly, for the profession and for you. Let’s always work on getting your office. to be the most profitable in business that we can. I’m the expert when it comes to coding and billing, which means also though, for payment and how do I make my office survive?

And it’s not just insurance. It could be cash, and we work a little bit on all those. But today, let’s focus on what’s going on with insurance coverage, particularly with the company Aetna. It’s at some nice changes, but it’s important to know though they’re increasing or having mandatory. , what do they actually cover?

One thing that you have to be careful of is understanding what codes they will pay or will not pay to make sure and assure that your claims get paid. Frankly, make sure the patient gets the best benefit and you’re paid for your services. So let’s go to the slides. Let’s talk about this acupuncture under Aetna.

And its mandatory coverage, but what does it cover is what I’ll say. Well, let’s talk about where Acupuncture’s really move or has moved. There’s a much broader access to acupuncture. Why does that happen? Frankly, it’s consumers who want it realize that the additional coverage that people are getting is because the want of customers out there who want it.

In fact, you’ve probably seen some of the commercials for the Medicare Advantage plans that literally use acupuncture as a way of marketing, so consumers are looking for it. Obviously, insurers. Why are insurers looking at it? Well, they’re realizing it helps, saves. But it also is sort of mandated based on opioids and some other issues.

So we’re seeing access there. Obviously the Affordable Care Act has helped because it’s made mandatory in five states, but now there’s been two that have been added. So for those of you who are in Oregon and Colorado, you now have also mandatory acupuncture benefits on all plans under the Affordable Care Act.

So that’s a good thing. That’s in addition to the other five states. Of course, the VA has created. . That’s nice. Medicare has not quite where we want it, but we’re getting there. And of course the big thing is the opioids have probably created most of that to be there. Why? Well, let’s take a look. 37 State Attorney Generals of National Governance Association have now endorsed and say they want more acupuncture.

They need it to be included. Why? There’s a few issues. For the most part, it’s just a money saver. If you go to an acupuncturist, that’s $600 compared to a primary doctor, which is 17. In addition, when a person contacts an acupuncturist, 30% of the cases compared to 70%, they’ve done the work. When people go to an acupuncturist first, it will save Medicare 230 million in its medical budget per year.

That is a big change and a big money maker. So insurance companies are starting to pay attention. The American College of Physicians for back treatment guidelines now indicate acupuncture. Even the FDA now says, Hey, for non-pharmacologic people should be doing acupuncture. There’s a bill going through Congress now in California to specifically make sure that there’s always access to acupuncture for people that are gonna need opioid.

To know they have that access, that there is something beyond taking an opioid. Well, even the CDC has gotten on board saying, Hey, when prescribing opioids, clinicians have 12 recommendations for acute subacute acupuncture. Non-pharmacological has gotta be part of that. They highlight the benefits, the effectiveness of it, and health insurance should continue to improve that because creating more access saves everyone, not including the people who take opioids and can overdose The CDC guidelines now, all specifically all.

about acupuncture. So I think what we’re seeing with a company like Aetna is what they’re doing is creating where people have more access. So you’ll see here in 2022, Aetna is added standard acupuncture benefits and new and renewing commercial health plans. So anyone who has Aetna through their job commercial plan, is going to have now acupuncture benefits.

That’s really cool. Aetna’s always had acupuncture benefits for some plants, but not all. And I’m sure some of you’ve run into that. You’re thinking, oh, it’s covered. Then it comes back, oh, it’s not covered cuz we only cover it for, you know, uh, this, uh, surgeries if you will for, uh, anesthesia, that type of thing.

Now it’s gonna have a standard coverage, which means all plans have it. So here’s the good news. If someone has. Do they have acupuncture? They do. In fact, it’s governed under their acupuncture and dry needling guidelines, which is their clinical policy bulletin, and it says, now standard NAPLANs STEM coverage of acupuncture for medically necessary indications.

So now here becomes the difference because it’s covered. Does that mean they cover everything an acupuncturist could diagnose or. No it doesn’t. It’s still limited, but that still means there’s a lot of access here. So they’re gonna limit it to the coverage things that they do. Now, this is what I wanna be clear on.

You wanna know what codes they will or will not pay for. This is what we do with our seminars. This is what we do for my network members to make sure you’re updated. So you’ll notice here the next review was just this year. They haven’t published it yet. We probably won’t get any updates to this probably until June or July.

I’m not sure it’s gonna update very much, but it’s going to follow along these lines. And it’s very specific about what it covers and you’ll notice it gives about 10 things that it will cover. It covers when medically necessary neck pain. It covers headache. Now those are relatively new. It used to not cover those, but it does say chronic.

So kind of that it’s been there for 12. Now, I think for many patients, chronic conditions like this aren’t hard to muster simply because it’s not always an acute issue, but a patient will go, I’ve had these headaches on and off for months. Well notice also it covers low back pain. Well notice it doesn’t say chronic low back pain, which now means it can be acute as well.

It also includes nausea of pregnancy, osteoarthritis of the knee or hip. So knee or. Does it cover arthritis? Are there is No, they’re saying near hip. So near hip pain. It also covers nausea from, um, chemotherapy. So, so-called chemotherapy-induced nausea, dental pain, which is kind of weird. So they, are you telling me that Aetna will cover for someone that has tooth pain?

Maybe they’re getting a tooth removed or something? Yes, they will. Not. Through their dental insurance, through Aetna, they also covered TMJ conditions. Now that’s something unique to them, CIG. Has a much broader allowance of diagnosis. But do you know Cigna doesn’t cover TMJ yet? Aetna does. So here’s what I will tell you.

If you code within this range, they’re gonna pay you you code with these conditions, they’re definitely gonna pay you. Just be careful of maintenance treatment. Notice what they define as maintenance treatment. Maintenance treatment where the member’s symptoms are neither regressing or improving is considered not medically necessary.

So I’ll simply put it this. , so long as you’re making the person better, it’s medically necessary. Now, the difficulty is once they are better, should we keep treating to keep them that way? My opinion? Yes. However, from an insurance standpoint, they want them to have a fall off and when they do, can treat again.

So this is where you might see a patient periodically throughout the year for acute episodes of a chronic condition. It flares up, we take care of it. We do a handful of visits if they’re. A month later it comes back again. But will they cover it? The answer is yes. Now they’ve listed the conditions, but what are the codes?

So let’s take a look at these codes specifically. They cover headaches and it covers migraines. Now you’ll notice migraine headache is G 43 0 0 1 through G 43 9 19. So you can well imagine. Wow, there’s a lot of coats from migraines Now there’s not 900. There is about 35, but they vary between those sections.

The most common one, G 43, 1 0 9, that’s your standard run of the mill migraine. But does it cover migraines? It does. Does it cover tooth pain? It does, but look at the code K 0.89. I bet many of you’ve never seen that. That’s literally a code that says disorders of the teeth. But because there’s no specific code for tooth pain, we use this one to document that in the notes.

It’s gonna have pain, but this is the code you use. It will also cover arthritis, but notice it’s arthritis of the hip, the hip, the hip, the knee. The knee, the knee. So it’s covering hip and knee pain. Now, you know what frustrates me about that? If you can tell me that acupuncture is gonna help with the knee and arthritis, pain of the knee, or.

Why would that not work in other areas of the body, such as the shoulder or the elbow? I think it obviously would, but again, they’re specifically indicating here it does indicate TMJ disorders, so TMJ dysfunction of any type or pain notice, neck pain, and then the low back pain codes. Then of course, vomiting of pregnancy, vomiting, chemotherapy, headaches, and that adverse ad, adverse effect of anti-neoplastic immunosuppressive drugs.

And notice, parenthetically, it says chemotherapy-induced nausea and vomiting. The fancy term is adverse effects, but it’s just chemotherapy-induced nausea. One quick note, this code has a plus at the end. Please note that this code any, anytime it’s an S or a T, prefixed to a code, it always ends in an A for acute.

And then the last one says Other specified post-procedural status. This is the code for post-surgical pain. They’re specifically indicating it dental, but obviously if you’re using any other type of post-surgical, this could work. One quick note please. Everyone take note of this, this code Z 98.89, even though it was published this way by.

it’s incomplete. It actually should be Z 98.890. So do write that down. Z 98.890, not 89. It shows you that insurance companies aren’t always infallible as well. But here’s what I’ll point out. If you code these two Aetna, I am going to guarantee they’re gonna make payment because these are on their list.

In fact, at the very top it says, these are the codes. If the selection criteria is met, which means is it chronic pain in some areas or is it, you know, manifesting that way. But you’ll notice they do something tricky. They say, parenthetically not all inclusive. Now that frustrates me because what they’re saying is these are the codes we cover.

We may cover more, but we’re not gonna tell you. Well, what I will tell you is generic. There’s some additional things that they’ll cover, and two of them, one of them is really gonna surprise you. I talked about the knee and hip arthritis and pain. What I will tell you is arthritis wise, they’ll cover here.

They’ll also cover pain. I have found through many people that pain in a joint will be covered like shoulder, elbow, wrists, so you’re pretty safe there. What they will also cover surprising. is anxiety. Now not full on depression. We’re not coding that probably from an acupuncture standpoint, but anxiety, depression, unspecified.

The code for that is F, as in Frank, 41.8. Now I’m pointing these out the other joint and this, um, anxiety just to say these are some other services. Some of you may say, Hey, Sam, I build a few other ones and they’ve been paid well. Great. I would like to say, let’s look at those and make sure we all know what they are.

That’s why I gave you those three extra ones, meaning joint pain and then of course the anxiety. What I will focus on though is to tell you be careful of coding things they don’t cover by example. You’ll see here it says Cervi. . That means neck pain. Now what if you have someone that has a strain of the neck?

You know, they do something active and they strain or sprain the muscle. If you coach strain or sprain to Aetna, they will deny the claim even though it’s neck. So what should you do? Don’t coach. Strain. Sprain. What? What is the symptom? What are the complaints a patient will have when they strain their neck?

You got it. Neck pain. So in this way, you’re gonna use the more generic, just tell me where the pain is. Don’t get specific that it’s spondylosis or other things of that nature. I kind of like that. It does keep it simple, but here’s what I’m again gonna point out. Make sure you’re looking at this list and if it’s not on the list, Make sure that you can find someplace that, okay, I’ve seen this elsewhere been covered.

This is one of the things we do at our seminars. More importantly, our network service. When members call me or get in touch with me, this is what I help them with is that here are the additional codes they may cover. I wanna at least give you a thumbnail though, to see what they do cover. So when they say they have mandatory coverage, I’m gonna say, yes, they do, but it’s for these codes.

So maybe take a picture of this screen, make sure you’ve got the right ones. What do they cover? Well, they cover acupuncture as you can. Well see, you know, initial sets, follow up sets where they’re manual electrical. But you’ll notice it also says tending the TDP lamp. No specific code. It says, well, what would that be though?

That’s probably just gonna be your hot lap. 9, 7, 0, 26 notes. It also covers dry needling. Will it pay an acupuncturist for dry need? Generally, no. What they’re gonna cover you for is acupuncture. I’m not gonna say an acupuncturist can’t dry needling, but I would assume it’s more acupuncture. These are the things they’re gonna pay you for, and quite frankly, they have a higher value.

I’ve had people ask me, Sam, can I bill dry needling? Well, I guess you could, but here would be my point. Why would you? The value of the dry needling codes are 50% of the acupuncture codes. Why would I bill a service that’s 50%? Than the actual service I’m performing. So I would focus in on the acupuncture.

Think of it, and this is something I emphasize when I come to you as a patient or when someone comes to you, guess what they’re seeking acupuncture. Therefore, what should you provide? Acupuncture. That doesn’t mean you might not do a little body work or some other things, but notice they’re not indicating these are covered.

I’ve run into some issues also where offices have had some plans with Aetna that don’t cover the. Now if the plan doesn’t cover it, does the patient have to pay for it? Well, they would assuming you’re out of network. But keep in mind, what I will tell you they will pay is the acupuncture codes. Now, be careful, stick with the codes I gave you because here’s their list of things they don’t cover, and look how far this is.

We have acne, pancreatitis, addiction, aids, Alzheimer’s, all of these conditions. If you code any of. , it won’t be covered, but let’s take this one here. Notice it says myofascial pain. Okay. What is myofascial pain? Pain in the muscles in some part of the body. Well, what if those pain in the muscles are in the neck?

How would you code it for Aetna neck pain? What if they’re in the low back, low back pain, and so forth. So in some ways, these things can be covered, like by example, carpal tunnel syndrome right here. What does carpal tunnel syndrome cause? Wrist pain or forearm pain, that’s what we code. So be careful they’re not covering these things, but they may cover it if you can keep it symptomatic.

So while I will say, I’m happy to see this, I hope it gets better, this gives us a good framework so that way you’re not fooling yourself. One of the difficulties that I’ve run into offices is they’ll say, Sam, my claim’s not being paid in its Aetna. Then they send me over and they’re coding something that’s not on the.

and I say to them, let’s make a correction. So these are the things that I wanna make sure that you understand that you can solve that if a patient comes in with a condition that clearly doesn’t relate to any of those, you know what you’re gonna tell them. This is not covered by your plan. However, here’s what we offer for cash patients, whether you’re doing a pre-pay plan or just a discounted time of service, that might be something you can do.

But I don’t want a patient thinking it’s covered and it’s not. Cuz do you ever notice, sometimes people wanna blame. when you are, when their insurance doesn’t cover, how is that your fault? It’s not. Obviously it’s their coverage and so don’t give them the false sense that it is covered. This is what we do at American Acupuncture Council, specifically the network.

You want someone to be helped to you. I’m an expert. I could become part of your team. Join us. You can call me, you can email. We do Zoom. We are here to make sure you’re getting. Many of you have lots of problems of things that don’t pay you we’ll fix that. Take a look. Otherwise everyone, I’ll see you next time.

Until then, I wish you the absolute best and continue doing what you’re doing. Take good care of your patients.


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 Thumb

2023 – It’s the New Year Where Are Your Patients?



So what I wanna emphasize for this first of the year is talking, where are our patients? How do I get my patients?

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.

Hey, good day everyone, and a very happy New Year. This is our first show this year. Welcome, and let’s get your year started off in a way that’s going to continue to help your practice grow, to help you continue to do what you like to do, which is help people get better. But of course, how do we make sure we help people get better?

We make sure by having patients and understanding where those patients are gonna come from. So what I wanna emphasize for this first of the year is talking. Where are our patients? How do I get my patients? This is a little different from our normal kind of just butts, nuts and bolts of coding and billing.

So let’s go ahead and go to the slides. Let, where are your patients and what are the barriers for them to come in your office? , you know, how do I make sure that I’m accessing? Because any practice to grow means we have to have more people that we can see. So I wanna focus in on understanding like how do I set forward my plan for the year?

And I want you starting to think about, have you written down any goals? Have you written down any protocols? Like what am I going to accomplish? And then start to look at some steps to do that. I think most things you have to do an algorithm. You’ll hear that term a lot, but it’s really just nothing more than a step-by-step process.

And the good news is when you set up a process, if you start doing something and it’s not working great, because now you can go back and fix it and change it. So that’s why the best invention often is errors, because with errors you continue on. It’s a scientific method. So we’re gonna create an algorithm for you.

And the starting point this year is gonna be setting for kind of that plan to promote my practice, prepare myself to get those people, and start determining like, well, how many patients can I see? Can I see five a day, 10 a day, 20 a day? And if whatever, I wanna see, am I seeing that amount? So I start with this though, for acupuncture, you gotta think of.

barrier to your care is the kind of, why do people know what you do, what you can help them with? Because if I drive by an office that says it does acupuncture, I’ll go, okay, but what does that mean to me in the general public? Think of it, ask your friends, ask acquaintances, your family even, and say, Hey, what is it?

Do you think I. , what do I help with? And you wanna start to notice that you’ll get a lot of varied dancers. Some could be very good, but many of them are gonna be very poor. And what I’m bringing this up for is that beginning to understand how do we educate people to understand what we do and the why they come in.

I mean, obviously you can look at the things that acupuncture helps people do. I mean, headaches, lower back pain, neck pain, arthritis, menstrual cramps, respiratory disorders, tennis elbow. But what about like worker? Can acupunctures treat workers’ compensation patients? Absolutely. Can it pay pretty well?

You’re darn right. What about personal injury? People involved in a car accident? How about veterans for the va? So think in those terms. Do those people who have that even though to come to you, think of how chiropractors really market towards car accidents and tell people, Hey, if you’re injured in a car accident, come see us.

What about many of you? We’ve had some pretty crazy weather across the US in the last few weeks. Do you think there’s been a few more car accidents than. I would think so statistically, which means some of your patients have been involved in an accident, are they choosing to seek care with you? And if they’re not, why not?

I would start with do they even know they can see you? A lot of times people think, oh no, my acupuncture wouldn’t be covered there. You bet it will. But how about conditions like fibromyalgia, anxiety and depression, chemotherapy, inducive, nausea, dental pain, labor pain, and I’ve just listed a few. But all of these conditions, by the way, have coverage under insurance, but it also has coverage under, if someone wants help and you can make them better, are they gonna choose you?

Yes. But you gotta give them the why. So here would be my, If you treat any of these things, how does anyone know you do? Is there anything on your website, anything on your social media, anything that purports you to do this? By example, if you look up to have acupuncture, coding and billing seminars, I’ll guarantee if you type that in, , we’ll be the first place up.

And the reason why is we put information out. We don’t pay for it. We just put so much information, we’re gonna be the first place because we do so much work on it. We want you to know this is the place to access it. So think in the same way for yourself. Are you creating a funnel? Are you creating a way for people to come to you to understand what you do?

Like if I typed in VA acupuncture and typed in my city, would your name pop up? Maybe not. Well, let’s go with the why not? Well, why not? Could be. They just don’t know. But I think a lot of it is, it’s just unknown. So we’ve gotta do a better job of putting stuff out. Like what articles have you written? What things have you put out about it?

Testimonials even, cuz remember, Google and things like that. Scrub websites to look for information, and they put those towards the top. The other factor of course, though, is just fear. Are there some people who are fearful of acupuncture? Ooh, I don’t know about the needles. So what do you create to make sure that people are comfortable?

Any explanation there? Or how about just money? . Is money an issue? Well, you bet it is. Healthcare in our country definitely is dependent upon how much money do you have? And if someone doesn’t have money, they’re not coming in. And this is where you have to look and go, well wait a minute. What about someone who has insurance by example?

I’ll give a couple of things. That’s just happened this year. The state of Colorado now has a mandatory six visits of acupuncture on all insurance policies. Wow. Well, all the Medicare, that’s an exception. That’s pretty. Oregon now has 12 visit. But how many of you there in those states have even promoted or understood or even know it’s happening?

We’ve gotta do a better job of communicating. Think of how many plans that you might be aware of that do cover acupuncture. If you take that insurance and it pays for acupuncture, you bet. I wanna let people know because if I have it and I don’t see your name, maybe I’m not gonna pick you. So I want you to think about what is a barrier for care.

It’s often money. I mean, it’s so much. So there’s actually a diagnosis for not having money to go to the. It’s Z 91,190. It’s patients non-compliance with other medical treatment and regimen due to financial hardship. Do you think that’s a big deal in our country? Yeah. We wouldn’t have a code for it. So this is where I think acupuncturists.

Are kind of that bridge because you’ve never been fully dependent upon insurance. Not that I wouldn’t use it if it’s covered, but you’ve also taught people the value of your service and that there is a value to getting it just paying out of pocket. My mom always said something that’s always stuck with me.

People buy what they want and beg for what they. . Think about that for a second. Does anyone truly need acupuncture? Now, I know we say that, but are they going to like die without it? No. So they have to want it. The good news is people who want things, those are the things they purchase. You see it all the time.

You ever see someone that needs to pay their rep? They buy the shoes they want in the interim. So you wanna put yourself in that side to understand that, create what you do. Because when someone comes to you think of the beauty of what you. Compared to just about any other practitioner. How many of you’ve had a patient that came in your office with a migraine or a headache or some type of pain and they tell you, oh, I’ve been to doctor one, two, and three, medical chiro, all of this, and they come in your office and think, well, I don’t know if it’s even gonna help, but I figure I’ll give it a try.

And then they get literally just a single visit or a few and go, I can’t believe it. It’s. That is powerful. There is value to that. When you can help me, I will pay for it. But you have to create the access so someone comes in. So thinking of it from this standpoint, are you gonna have a lot of people that will pay cash?

Absolutely. You will. I think a good portion of your practice should be cash, but also insurance and it should ebb and flow. You shouldn’t be interdependent on one or the. Because let’s face it, someone who has really good insurance is gonna want to use it, so I want to access that. But if they have very poor insurance, I’m not, and I’m gonna put them in cash.

Or if they have no insurance, we know from the National Institutes of Health that people don’t have as good a coverage for acupuncture benefits. They’re just not as good. They’re there, but not as good. But the data from that shows people are more willing to pay out of pocket for acupuncture because you have created that.

So if they are, what can I do if I’m treating a cash patient? Well, that’s pretty easy, you treat them. But let’s talk about how other professions deal with it. So we can kind of take a page from their book. Take a look at this. This is from the American Physical Therapy Association. This is something they wrote in 2022, and they indicated that higher copayments decreased the likelihood of people coming in.

Well, that’s kind of a duh, of course. . If people have to pay more outta pocket, they’re less likely to come unless they can place enough value to it. Now, here’s what’s interesting for them. It indicates that as soon as a person pays $30, about 30% of the people or one third of them leave, they don’t come in.

And so I thought when I saw this, I thought, Hmm, is that something that’s gonna apply to our profession? Acupuncture? And it turns out, actually in the article at the end, it says, for PTs it does, but for acupuncturists it. So it shows that I think when people choose acupuncture, they understand that, you know what?

I know my insurance is not gonna cover a whole thing, but if it covers a little bit, great. So that $30 is much less of a barrier. So keep in mind, the more value you give, , the more someone’s willing to pay, again, buy what they want. Here’s something else this article pointed out. Now, it’s not specific to Cairo or it’s not specific to acus, but I think we can take something away about Cairos.

Physical therapists are a little jealous of chiros, and I’d actually say a view a bit because how you have branded yourselves. You’ve never been fully dependent upon the insurance model, and I think that’s why so. Medical models can have failure because if you’re trying to do all cash, oh, my insurance doesn’t cover, I’m not coming in, because you’ve always dealt with both ends, I think it gives you a better way of dealing with that.

So it’s not quite as much a barrier. And I think here it shows the value of the service. So let’s talk about, that’s the barrier, but where are these patients coming from? Well, in my opinion, you’re gonna have 12 types of patients that can come in your office. You’re gonna have three methods. That’s kind of how when someone pays out of.

and then nine different sources that could be insurance, which you can see here. Those nine sources. I’d like to access some of them. Here’s what I would point out. Some of these are not that good. Like I’m not that interested in some of those HMOs that pay only like $35 a visit, so those I’m not too excited about.

But what about a standard insurance that pays several hundred? What if you’re in Southern California and treating someone that’s a longshoreman or a New York with New York ship or Florida with Anthem and these plans? Some of these plans can be excellent, va. How about an auto accident? Think of it. If someone’s in an auto accident, would they even think of coming to us?

How about work comp veterans? If, if you treat VA patients, you know those pay well, how do you get them to come in your office? Think about when’s the last time you have something out letting people know. Do you have a sign up that says you treat veterans or is there anything on your website? There’s lots of tools.

To do that. I mean, heck, what about Medicare? Now you think, oh, Sam, come on. Medicare only covers chronic low back pain has to be supervised by an md. That is correct. That is true Medicare Part B, and that’s a little difficult because you wouldn’t need a medical provider to work with. But what about Medicare Part C policies, so-called advantage plans.

By the way, close to 50% of people who have Medicare have that type, and most of them have routine acupuncture, which covers quite well. So what I want to access those patients, I would, but how would someone know you take. If you don’t have it on your site, well, obviously y’all take cash. People will come in.

Well, someone who pays cash, great. They just pay for the service. But let’s talk about what other things might there be to create less of a barrier. What if you have a cash price but you give a small percentage off at pay a time of service? I like that. I mean, that makes sense to me. You know, if your visit’s a hundred and if you pay cash, it’s 90.

That’s fair. You can charge a hundred for insurance, 90 for. Because you can give a small discount, very small, five to 15%. The one exception is California providers. Of course you probably are familiar, but outside of that, a small discount, that’s fine. But does that create a barrier or less of a barrier for the patient to come?

I think so. But what about something else? You ever heard of prepaid plans? What do I mean by that? Someone comes in, instead of buying one visit, they buy 20. So I want us to think of a minute for business models, cash. Can you just waive fees? The answer is no. You can’t say, Hey, I won’t collect it. So be careful of that.

That doesn’t mean you can’t have hardships here and there, but you can give discounts. You know, as I say, the five to 15%, and I wanna focus more a little bit on prepaid plans, but I wanna look at it from this standpoint. You’ve all seen modern Acupuncture. Is that a very popular place where people go, you bet.

How does that model work and think in this way? Are you doing anything to adapt your office? Well, let’s talk business for a second. , you are all familiar or many of you should be familiar with the company Sears. In 10 years, most people won’t be because the company doesn’t exist anymore. It’s bankrupt. Why?

It’s really funny. Sears was Amazon before Amazon, but no one at Sears had the wherewithal to look and go, Hey, when Amazon was coming in and shipping things, Sears already have that inform. They had a catalog. Why didn’t they have it online? People could ship. If they did that, would they still be around? So I want us also thinking of adapt.

Think of the company, modern Acupuncture. Have you ever thought of, could I make that model maybe work a little bit? I will say pretty much every state, so long as there’s a modern acupuncture in your state, it’s allowed. There’s some restrictions I’ll go over in a moment, but what you’re dealing with when you’re dealing with a modern acupuncture style is the person is buying instead of one visit at a time.

Maybe they’re buying 10, so they pay 10 up front. Maybe instead of it being 75 each, it’s 50 each, so it’s $500, but it’s paid up front. One lump. I like that. Patient’s more committed to come in. The only thing you have to make sure is if they don’t want to come anymore refund what they didn’t use. And a couple of things.

If you’re in Montana or in Florida, you do have to put the money in a trust account. Florida’s a little unique that if it’s under 500 you don’t, but can’t be more than 1500. What I will say is just know your state. It’s one of the things we teach at our seminars to make sure you’re compliant. We do with the network, but I’m gonna say this to me, would be a good avenue because there are people going, well wait, I need to come 10 times.

That’s your recomme. But you know how it works. After two or three visits, they feel pretty good. So they stop coming because they go, well, I feel good enough and I don’t wanna pay a hundred a visit, but what if you offered it so it was 50 or 75 prepaid? Chances are they’re gonna be more committed to it.

That part you might want to think of because that’s exactly how the modern acupuncture model works, and being modern acupuncture is the biggest area of growth in your profession, wouldn’t you think you may wanna adapt to that? I mean, think of it this way, did target adopt the 99 cents? a little bit. You can still go into Target and buy expensive watches and so forth, you know, electronics.

But do they also, when you first walk into Target, have a small 99 cent store? A few things. So there’s nothing wrong offering. A little bit of both. Don’t have to be mutual exclusive. You want to think of, I wanna accept patients, I wanna accept patients who can pay the fee. That’s reasonable. And you certainly can come up with some reason for that.

So think along the lines of where are these patients coming from? How do I access them? How do they know I do it? If you’re doing prepaid plans, how does anyone know? , are you putting anything out there to let people know this is how we can make care more accessible to you? Remember, think of how you shop.

Think of how you choose things. Now, the good news as a healthcare provider, a lot of it is based on just good word of mouth. You know, often when the best place to get a patient referral. My acupuncturist, the one I go to personally, is not very cheap. I have very good insurance, so that helps. However, I will tell people when they go to her, I’ll say She’s fantastic.

She really is helpful. She’s thorough and all those things, and I tell them, Hey, she’s not the cheapest, but she’s really good. No one I ever sent to her goes because they think she’s cheap. They go because she’s good. And I want you to think of, is that what people are saying about you? So you gotta start to create like what is my image?

What am I doing and what type of business I’m promoting. I have a friend that’s a very expensive acupuncturist. She’s very, very busy, but she treats a certain type of clientele. She knows her market. Start to look and go, what is my market? How do I do? Because your success is dependent upon you. How are you setting up to get more people, whether it’s cash, insurance, or ait.

you might wanna get some ways to help that. We do seminars, we do continued education. That helps that. This is our website for the network. We have upcoming seminars this weekend. It’s gonna be on Eastern time zone. In two weeks it’ll be on the eastern, uh, central time zone, but it’s there to help you understand what does it work in my state?

How do I make all this work? I can go into much more detail and really give you help. In fact, I can become part of your staff. You can join our network where Sam is your staff. Call me. Email me. We want to figure out how to make sure your office is success. Your success is ours. So let’s start the New Year’s.

Let’s create a plan. Let’s start getting things together. Probably want to come to me for a little bit more help, but this is gonna be a good starting point. Until next time, everyone, I wish you the best. Good success for 2023.


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The Pros and Cons of Joining an Insurance Plan



Hey, should I join this plan?  Is it worth it? What are the good ones? Which are the bad ones?

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.

All right everyone, and welcome to another edition of To The Point with the American Acupuncture Council, and thank you to the American Acupuncture Council for this opportunity, but also as an opportunity for you to get more information about how to make sure you can run a well run, well-rounded practice, one that you enjoy doing, one that can also be profitable.

On today’s topic, what I’d like to discuss is manage care, joining an insurance. Let’s go to the slides. Let’s talk a little bit about that. Cause it’s a very common question I get as a coding and billing expert and doing this for a number of years with seminars, one of the main questions I get for members is, Hey, should I join this plan?

Is it worth it? What are the good ones? Which are the bad ones? And what I wanna do with this is try to give you a little bit of a primer on what you should do or understand when you join or think of joining, what are the things that you must consider? So managed care plans, I like to think. Is it worth it?

Is there a value to join or not to join, if you will, is the question. So let’s focus in, Let’s really talk about what we mean by the term managed care. Often, I think we misunderstand it, but in many ways managed care just means that the insurance company is truly managing the providers you’re joining.

And you’ll often hear these terms like a preferred provider or a member provider. And these are often what we call ppo, preferred provider organizations or HMOs. And these are plans that the patient is given incentive. To see the doctors within the plan, generally with lesser copays, deductibles, or within hmo.

Of course, it means if they go someplace that’s not in the hmo, there’s literally no benefits, so we have to look whether or not this is worth it. So here it says, insurance plans that provide or that have the provider acupunctures to join in order to gain access to get the insurance payment. Sometimes remember, You can be outta network, and this is one of the things to consider.

Do you have to join an insurance to be paid by it? And let’s make this clear on a regular insurance plan. Once you are licensed, you may bill and access benefits. Unless the plan has a provision that they only pay for providers in network. Be very careful. A lot of people when they first start will think, Ooh, I have to join.

In order to gain access and you don’t. So first thing is make sure, does the plan have benefits that are out of network? Meaning any willing provider or do they require in network by example? Some of you’ve probably have seen these Medicare Advantage plans, Part C plans. They’re advertised quite heavily right now.

Pay attention to on television commercials, and you’ll see companies like United and Cigna and others advertising that there’s acupuncture benefit. Bear in mind, many of these plans don’t require that you join as a provider. Just be willing to accept the patient. Now, when you do accept the patient, you’re gonna be limited to their fee schedule, but at least that way gains access without joining.

Now, the other side would be, if I join, would it be more likely for the patient to come to me? Does it incentivize them enough to choose me as the provider? So again, the provider gains access. But we have to make sure, is that access we could have already had. The real issue here, I think that we want to consider is your business is that it’s a business.

I know it’s a practice and you’re there to help and all do all the good things to care for someone, but at the end of the day, it’s still a business. So like with any business, we have to make a business decision on this type of plan. There is a trade off. What is the trade off? The trade off is if you join, you gain access.

In other words, the patient has incentive to see you. Now, for me, the big issue is does the patient have complete access or is it one that they could still go anywhere? So the bottom line though, it gives you access. It allows the patient to come and see you and have a benefit. And let’s face it, people who have insurance are more likely to go to the doctor than those that don’t.

I’m sure you’ve all witnessed that. You all probably know someone right now, maybe even a family member that needs to go to the doctor but is not going because affordability, they have no insurance, no benefits. They’re not going. So this often is why people with insurance generally go to the doctor more because frankly they have access.

Always think of what’s the barrier to care. Often money. So this may help with that. However, talking about money, the trade off is yes, you may get more patients or at least more access. , But do you get paid? You’re saying money. No, you don’t. Mostly, and I’ll say every time you join a plan, there’s always a reduced or limited reimbursement you can collect.

Now, that reimbursement could be decent enough that it’s worth it, but it may be too low. So one of the things to consider is there enough value for me to do it? In other words, the choices can, the volume. Make up the difference, and in some ways, think of managed care, and this sounds awful, but Managed Care, in my opinion, in some ways is the 99 cents store.

The 99 cents store is a very popular store, but how does that store really function? They have to sell a very high volume of goods because they’re only 99 cents. So you have to think of it when you’re getting reduced payment. Your volume has to go up. Now, this is something that’s a little more complicated for an acupuncturist.

Say, compared to a chiropractor, you have to provide all the services that you deliver in a acupuncture, excuse me, in a chiropractic or physical therapy setting, they can have assistance. Acupuncturists are pretty much out of the loop on that, so it means, for the most part, you have to do everything, all the care, and of course, your care is very time.

I. , Let’s face it. Each set of needles is 15 minutes. And while the eight minute rule does apply, even if you’re doing three units, you’re spending close to 40 minutes, maybe 45 minutes with that patient in your. That’s a lot of time if you’re only getting a very minimal amount of reimbursement. So you’ve really gotta kinda weigh out the pluses and minuses.

And what I think you should do is start to really to look at these plans from a true business standpoint. Like just when you take your first business course in college, one of the things you learn is, Hey, can you make a widget? How much does it cost to make the widget? How much can you sell it for? And how many can you sell?

That depends on how profitable the business can be. So what I’d like you to do is keep it relatively simple. Get a piece of paper, draw a line down the center on one side, put yes, one side, put no, this is exactly what I do with my network members. It can be a little bit more detailed. Obviously in this form we’re limited, but this can give you a good starting point.

Am I gonna join something? The yes would be if it’s exclusive. If the patient has no benefits at. Without you being in the plan. To me, that’s a big yes to join because otherwise there’s no access. What if you’re in an area where there’s a group where a lot of people in your area belong to it?

Would you likely wanna join? Because if they can’t come to you with their insurance, are they still gonna come in or are they gonna choose elsewhere? So an exclusive plan to me is a big yes. However, keep in mind, what if it’s non exclusive? And be careful. A lot of PPOs prefer provider organiz. Are not actually as exclusive as people think.

An HMO is one where the patient has to go within the plan, but a PPO is one where the patient can still choose to go outside of it, and you want to check to see if I join, could the patient still come to me? One of the things I will be concerned with is often people join these plans and all of a sudden realize, Hey, I’m getting less money.

I’ll give an example. Sigma Insurance has done this. There’s a group with a SH that if you join. You get a limited reimbursement, but if you’re out of network, your reimbursement’s the same but or is higher actually. So from that standpoint, often you really wanna look to see if it’s not exclusive, what type of access does a patient have?

And here’s another example. United Healthcare generally will pay providers better that are out of network. And you’re thinking that doesn’t make sense. That’s how the plan works. It just pays more. Now, the difference could be though, maybe they don’t find you because you’re not in the network, or sometimes their deductible could be higher for out of network providers.

So I look first, if the patient could come to me anyway, what’s the incentive here? So you have to look at what’s the balance and how’s it gonna draw someone in, because at the end of the day, it comes down to if I’m gonna join, even if it’s exclusive, is the pay reason. Does it pay me enough to really make it work?

Bear in mind, there are some plans for acupuncture that I kid you not pay as little as about $40 per visit, and that’s all inclusive. I don’t care what you do, you can do five sets of needles in a therapy or two sets of needles. You’re still getting, the $40. And also keep in mind, this is something that surprised someone the other day.

They had a plan that pays 63 42 with a $25 copay. And they had the mindset that the plan was gonna pay 63 42, and then you charge the patient 25 on top of it thinking they were gonna get close to $90. The reality is, in a plan like that, when it says it pays 63 42 with a $25 copay, they’re going to allow 63, 42 minus the 25 that the patient pays.

So the total you. Is 63 42 with 25 of it coming from the patient. So we have to look even at that amount. Is that reasonable? Is it enough for me to really make my office work? What if it just simply pays too little? know, You look and go, I can’t do that. Work for it. You know yourself as a practitioner, some of you could spend maybe 20, 30 minutes with a patient.

Some of you might spend an hour or. The more time you spend, the more value to the service. You can’t really survive. If you’re seeing a patient for 40 bucks and spending an hour or plus, I don’t think you can keep your practice helping. Let’s face it, that means you can make a max of maybe 300 a day, and I’m not sure $300 a day is gonna keep enough for your office as well as your home expenses.

The other fact to think of though is what if I joined? Does it bring me many new patients? Would it give me access to people who otherwise wouldn’t? That’s something to consider. What if all of a sudden you can get many more patients? Realize if an increase in volume happens, then that could still increase the bottom line cuz you’re seeing more people.

The limitation as an acupuncturist though, is how many people can I see per day? There’s limits there. There’s only so much time in the day. If you spend an hour with every patient, all you can see is eight and eight hour day anyway. So something to think of. But if it brings a new patient, I think.

That’s not a bad thing. You know what? If this is a new patient that you wouldn’t I otherwise see? And bear in mind, I had an office once that said, Sam, I’ve joined these plans because when I join, these people come in. But they often refer me people that aren’t part of the managed care plan because they have friends.

And so I thought, Okay, tangent. Generally I can see where there may be a benefit there, but those are all the things to weigh out because bottom line, what if they’re already a current patient? And this has happened to me. I had an office that they joined. And they were getting a hundred plus per visit.

When they joined, they got dropped to 60 and I thought, didn’t you find that out before joining? So before you join, really ask the hard question, What does it pay? Realize, because of the no surprise act, the insurance company have to be forthcoming with what they’re going to allow. So be careful before you join, really start to weigh out all these factors, and you may look at some other things as well.

Sometimes these plans, as America Specialty Health, may request that you send pretreatment author. After a certain number of visits. Now, I won’t say those are very hard, but that’s a lot of extra work or at least extra work that you have to do after five visits. Is that worth it when you consider the time that it takes to do it Now, what if it even only takes 15, 20 minutes?

That’s still time. So again, we have to weigh all those factors in. Now, if it has a lot of things that you’re required to do, maybe. If it’s relatively simple, and again, you have to learn to make it work and understand what they’re looking for. But you can see here this lens toward be a little bit more scrupulous.

Don’t be afraid to be a little bit more focused on is there enough value here? Now, the good news is, let’s say you join something and it turns out to be horrible, and you’re like, Oh my God. You can always drop out, but bear in mind, dropping out is not immediate and be also conscientious that when you join something, always ask.

What other plans will this join me to? By example? If you join a group like multi plan, it’s not just one. It often attaches itself to several things and be conscious that you can sometimes opt out of these types of plan. You can say, Okay, I wanna belong to this one, but not that. So by example, with some as H policies, you can choose to opt into Blue Cross, but not Blue Shield or Cigna and not Aetna.

So before, always look at what do I really want to join? What’s good for me or what’s not so good and see about opting out. At the end of the day, it’s all about the value, The business value, I would say. Think of what your cash rate. Cash rate is meant to be simpler, less because there’s less work. I’m not saying insurance coding and billing is hard, but there’s more time.

So often for cash patients, we’ll offer like 10% off because know, we don’t have all the other background paperwork. Okay? So think of that rate. In my opinion, I need at least that to be darn close to what my cash rate is. Now, obviously I don’t think anyone has a cash rate as little as. So I’m looking at 60 or 70.

So a lot of these plans I look at and go, I’m not so sure unless I can really make it up in the volume. But I wanna look at does it match that, or at least this, Have you ever thought of, what does it cost to treat a patient in your office? Really, know, what’s your bottom line? What does it take for me to just keep my office open?

Now how do we do that? What I’d like you to do is to take your office over. What does it cost for your office? And that includes your rent, your lease, cost of needles, table paper, everything to rent in your office. You know what I’d actually include with that? I’d include student loans. I really think that’s part of your office cost.

But anyway, take your overhead, then divide that by the average number of patients per month. Notice I didn’t say, or excuse me, patient visits per month. Not patients, but patient visits. So by example, let’s say your overhead cost is $4,000. That’s what it costs to run the office, and 25 visits per week or a hundred per month.

That means in order for you just to break even and pay for the office, you have to get at least $40 per patient. So when you’re looking at a plan like an ASF that’s paying 40, you’re making nothing. So unless you can increase the volume, this really doesn’t help. So be careful before you decide to choose.

You cannot do this at a loss. It’s gotta be with some level of profit. Now, maybe you can have an office cost that’s only $15 or $20 a patient. So some things to consider, but I really want you to look at the business side of it, and this is the part maybe we don’t like doing. You want the school to be an acupuncturist.

You are good at what you do. You help people. The part we don’t like is, What do you mean I gotta deal with the business end? And that is an important part because unfortunately a lot of acupunc. Within three to five years of graduation, don’t practice because they simply couldn’t deal with the business side of it.

And I want to help you with that to say, could this make a difference? Now what if you join this plan and though it doesn’t pay very much and that doesn’t meet the overhead expense, but what if you have an office, you’re not very busy, and you have openings for another 20 visits per week or more.

I would rather fill them with these than not have them at. And then maybe you can build the practice from there on other referrals and get them sold on maybe maintenance care. So there’s some things to consider here, but I want to be careful that if it’s gonna take away an existing patient and all of a sudden now you’re replacing a hundred dollars patient with a $40 patient, not a good idea.

Realize that under ash, depending on the plan you join, whether it’s Cigna or others, the reimbursement can be as little as 40 to about $90, which means in this aspect, you could be making $0. Actual profit to maybe 45 per patient. Now that’s not awful, to get 45. In fact, I think we can make overhead a little bit lower.

So let’s take a look at like Ash with Cigna. And I’m gonna say this varies from state to state. I’m giving you just one state here, and you’ll see here they allow 51 for the first set, 38 for the second, but it’s just a maximum of two. Means you’re gonna get $89, you’re not gonna build multiple sets or therapies.

They’ll either pay two codes and the max is 89 per day. Now is that. No, I think that’s reasonable. I think that fits a lot of people’s cashes too. Two sets, meaning you can do it 30 minutes, they do pay separately for exams. But let’s be honest, notice the exam price are only 20 to $40. So when you’re getting managed care, you gotta know that I’m gonna get probably less than a hundred dollars per visit.

Can I make that work? Does the volume hit it? And remember, this is an ash tier. When you join Ash, and I’m not saying this is negative for ash, I just wish they paid more. Most acupuncturists when you join is gonna be put at a tier three, which means when you’re a tier three, after five visits, you have to send more information about the need for care from the patient.

Now, as you’re in the plan for a length of time, you may reach a tier six where you don’t have to do that because they know that you’re trustworthy. You’re not over utilizing. But you can see here, there’s extra work. Now, again, I’m not against it, and there’s ways to work with that. That’s one of the things I do with our network services to help you with that.

But I want you to also look at this overall and know yourself. If you know that you spend more time, if you know that you do not like to do extra reports, this may not be for you. You’ve really gotta make the hard choice of is there enough value for me? I’m not against joining, but take a look at the plans and what the incentives.

How does it increase the volume of patients? Does it bring in 10 general patients? So let me give you a kind of a quick primer about what must or should you join. I’ll never say must, but these are just my opinion. I will certainly say if you’re joining the va, that’s a win-win, meaning there’s no negative to that, in my opinion.

If you join the va, whether you’re on, Texas or west of Texas or East with Optum, Tri West, or Optum, when you join, there’s no cost to join. And the only access is to VA patients. Now, if you get a VA patient, it’s great that VA patient’s probably gonna equal 1500 to $2,000 of reimbursement for the amount of services they offer.

So I’d say, Okay, there’s a value there. There’s no downside, because if you join the worst thing that happens, you don’t get a patient. If I get just one or two a month, that certainly could be worth it. So I think for me, there’s no issue there. I think HMO plans like Medicare Part C. Now notice I’m saying Medicare Part C, I’m not talking regular Medicare.

I’m talking the Part C policies with the additional acupuncture benefit, those I have no problem joining because again, this is exclusive. If you’re in, you can see the patient and these can actually decently reimburse. They give access not only to acupuncture, but to exams and therapies as well. So those I have no problem.

Again, no cost to joining. What about optional plans? You know what? If I wanna join an a sh or Primera or Blue Cross Blue Shield look to see what does it do, what else does it join you to? I would start with, is it exclusive? Is my number one issue. Cause I think if I wanna bring people in, think of how many times you’ve had a patient come in and has this ever happened to you?

Have you ever had a patient that you gave a hardship? that you hardly charge ’em anything, but you wanna be helpful. That’s what you do. And in turn, that patient wound up referring you many patients. So realize there’s more benefits that could be there, but you wanna start to weigh that out. Is there enough value outside of this?

I’d really have to work with the individually to say, Okay, let’s talk about what area you in, What part of the country, what county, what city? Who is insured there? What type of plans are you seeing? Is there enough a benefit to do it? Does it pay enough? Now, as you can tell, this is complicated. The good news is you’re never stuck, but you do wanna make some choices and decide whether or not it works for you as a business provider.

At the end of the day, you are providing a service that has a value, and that value has to be enough to pay for you and your office, but just your home cost as well. So it’s something to consider. I would say certainly take some time to look through it. Don’t be afraid to be a little scrutinizing, and if you jump in one.

Don’t like it. You can always jump out. Keep in mind though, one thing, you can join one plan and not necessarily have to join the other. So when you join like a sh, make sure you know that. Can I opt into one plan? Maybe I belong for Cigna, but not for Ner or some of the others. So keep in mind to always look at all the aspects of whether or not, what do I have to be in?

What am I automatic or what are optional? Cause I would certainly not wanna be part of personal injury or some of these other things that may be involved with them. And that’s what we do at the American Acupuncture Council Network. For some of you, You may have already been familiar with this, but it’s a chance for me to be part of your staff.

Give me a call, send me an email, do a Zoom meeting with me, and we help your office. Take a look here. Just go to our website or do this QR code. We’re here to help. We always want to have you to have the best possible practice you can. That’s really our goal. So we’re always here to serve American Acupuncture Council Network.

Here’s our phone number. Go to our website. I will say to all of you, best wishes, and don’t be afraid. Make that choice. Decide what works for your business. We’re here to support you. Until next time, everyone take care.