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Getting Paid Directly from Medicare


So I want to talk about Medicare because there are so many things that are confusing or misunderstood or misrepresented…

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.

Billing expert for acupuncture and the American Acupuncture Council network, as well as the American Acupuncture Council Malpractice Insurance. With another time to get with you to update you on what’s going on, what’s changing to make sure your practice is thriving. Remember the American Acupuncture Council was always your partner.

If you have a question and need an answer, trust me, we’re there for you. So what are we going to talk about? Medicare. So let’s go to the slot. So I want to talk about Medicare because there’s so many things that are confusing or misunderstood or misrepresented that I think are going about. And I’m getting so many calls and requests for this, whether it’s people on my network or coming to seminars, what is going on with Medicare?

What does it really cover? And what is the. Differences between Medicare part, B and C who pays me. So I want to make sure there’s a clear understanding. Regular Medicare part B is what you see on the left side here, that standard Medicare card, but you’re going to know a lot of people have something else called Medicare advantage.

And so we want to kind of talk a little bit about that to make sure there’s a really clear understanding of what’s going on because of course you are being in a. With people requesting information or saying, I heard it’s covered. Take a look at some of these ads. The upper left is from a RP where they put out, Hey, Medicare will cover acupuncture for back pain out or regular med take care of patients sees these types of things and thinks, well, I want to get the care because notice even blue cross blue shield has an ad for it.

In addition, here’s another one, indicating a zero acupuncture for 24 visits. And this was a commercial where they literally show acupuncture on the commercial. Realize acupuncture has become a commodity. For these plans because it’s their way of enticing people to get their plan. Ooh, join ours because there’s a benefit.

Now the confusion of course, is what are the differences between this part a and part B and really what is Medicare? Well, who are the Medicare patients? Will Medicare patients, is it going to be people 65? Obviously, at least as long as you’ve paid into Medicare, I think for 10 years you will automatically get Medicare benefits when 65.

But remember Medicare is not just for people over 65. There could be some people who are younger that have a permanent disability and as a consequence are entitled to Medicare. So don’t be surprised when a Medicare patient is younger, but it also could be people with end stage renal disease, probably not ones that we would see, but certainly the.

Now what’s going on with Medicare is understanding the types of Medicare. Now we have standard Medicare part a, which is the one everyone gets it’s hospitalization when you go to the hospital. But the one we’re speaking of is very typical as well. And it’s Medicare part B I’ll call that traditional Medicare.

So this is the original Medicare benefit that covers going to the hostel. Going to a doctor’s office and having a drug benefit. Now, the good news is these people can use it. Anyone within the system, does it matter? The state and Medicare pays its portion and the patient pays 20% of it. So not bad, a good, nice coverage for people who are over 65, for those that don’t remember prior to the implementation of Medicare, many people who are older would literally go bankrupt with any illness.

So this has been something that’s been quite the good, safe. Bottom line though, is what’s going on for acupuncture? That’s what we’re concerned about. So you notice I have it in red here and it says acupuncture is covered, but it says for chronic low back pain, only under direct supervision of a medical provider.

So all of a sudden, well, yeah, But it’s only covered when done under medical supervision. So that makes it somewhat limited. The low back pain of course is limitations for it as well. But nonetheless, the supervision makes it hard. And part of that reason is acupuncturists have not yet become Medicare providers.

We need to get a bill, which we already have one going. That’s going to make acupuncture providers under the social security, social security. To be part of Medicare. So until we get that, we’re going to be stuck with this type of issue of needing the supervision or, or referral, if you will, from a medical provider, that bill is being moved and hopefully we’ll see something in the next couple of years, but this is kind of the cart before the horse.

If you think that Medicare was really going to first do a study of how good acupuncture could be to see if it was working or not, the evidence was so overwhelming, they decided to cover it. The problem. The cart before the horses while they’re covering it. But because acupuncture’s can’t join, Medicare is still had to have some tangential way of getting in, which means under the medical provider, meaning for traditional Medicare part B, it still has to be billed by a provider within Medicare.

And that’s limited to basically medical providers, so that one’s a little more complicated or a little more difficult, but nonetheless, still the late. Let’s talk about though. Also what a lot of you are experiencing and misunderstanding is there’s this second type of Medicare that’s often referred to as a Medicare advantage plan, or also known as a Medicare parts seen.

I know of those letters can be confusing, but I like to think of it as a Medicare advantage plan. What a Medicare advantage plan is a way for a Medicare patient to literally chip trade their Medicare benefits to this point. And then this plan takes over for the benefits and it’s under companies like United healthcare, Aetna, Cigna, all these ones offer them and they have to offer all the same benefits as regular Medicare.

Sometimes it’s actually even cheaper. Which to me is interesting. When you think of it, how is it that we can manage Medicare patients for like 500, 600 a month in premium yet when we buy premiums for someone that’s younger, it’s thousands of dollars. Well, that’s because it’s insurance companies making sure.

Bottom line though, is that these plans have to cover exactly as Medicare does. So in other words, they have to cover the low back pain, just like Medicare to however many of these fines. And you’ll see this in a second. The last bullet offer extra benefits like acupuncture, and these can be built directly by an acupuncturist to the plan without being part of quote unquote.

Now, some of these plans may require you enroll, and I frankly will have no problem with enrolling because it only gets you into the one and gives you access. These can be pretty darn good, but let’s understand the. Traditional Medicare part B regular. Again, acupuncture is a benefit now, but chronic low back pain only, and up to 20 visits a year or so, not bad.

What it says though, is that the there’s 12 visits within 90 days. And assuming the patient improves another eight, the difficulty for us is that an acupuncturist can perform. But it must be supervised by a medical provider. And this could be an M D a D O a PA, an NP or a CNS. And so these are all medical providers that are enrolled in Medicare.

So in other words, you’re working kind of for this person, if you will, it’s not a referral, but something you’re working with because it has to be built by. So to take a look at it, this under this national coverage determination, you’ll see here. It says the most recent is that it will cover for chronic low back pain.

And that is defined as back pain. That’s more than 12 weeks. Now that doesn’t mean like, oh, I’ve had it exactly 12 weeks, but think of how many Medicare patients talk about all my. I’ve had back pain on and off for the last 10 years. Well, by definition, that’s certainly going to be chronic. It certainly can’t be associated with other inflammatory diseases like infections or metastatic cancer, but traditional, as most people get back, pain realized 85 million people a day habit.

That kind of makes sense. It will be covered. Now here’s something interesting. Obviously you’re all aware that back pain codes updated and part of the complications in dealing with this when they update. Medicare published what codes they were going to allow, even though M 54 50 is one of the codes new for back pain under the Medicare guides.

What they indicated is that it’s only going to be M 54 51 for routine progenic or other specified in 54 59. So make sure if you’re billing Medicare, part of the reason if you’re getting denials is you have to update to one of these two codes and bear in mind. There are some payers that have been delaying until April 1st, for some reason, but.

Those are the codes. If it’s back pain, notice the code, doesn’t say, uh, chronic. It’s just the idea. And that’s why M 54 59 is the more likely now it pays up to 12, but notice it says an additional eight sessions will be covered for patients demonstrating improvement. I think that’s fairly straightforward.

Most patients, in fact, getting acupuncture with back pain, almost always improve, obviously. And it’s just as long as that’s there they’ll allow additional eight meeting up to. Now the complication here is this is not a yearly benefit in the way you might think, meaning it starts over in January. It’s a rolling year.

So by example, it says if the first services performed on March 25th, The next service beginning of the new year, can’t be until March 1st of the following year. So they do it as a rolling month. So it’s literally 20 visits with any within any 12 month period, not January to January, but it could be from March to March and so forth.

Now the complications here is that physicians can furnish it. Of course, medical doctor certainly could physician assistance, but they also have to have some additional licensure for accurate. Bottom line is you’ll notice here. It says auxiliary personnel can do it so long as you have a master’s or a doctoral degree for acupuncture, which is going to be all of you.

And therefore you can provide it. Now here’s the problem you’re providing it, but it says here, auxiliary personnel, furnishing acupuncture must also be under the appropriate level of supervision. Now, a lot of people have misinterpreted appropriate level. It’s thinking, oh, it’s just based on a referral.

And they come in the office, unfortunately, not that simple under this rule, that’s under these two regulations I have, here are 4, 10, 26 and 27. You have to be present in the same office. So it means you gotta be in the office with this medical provider when the service is delivered, they bill for it.

But yeah. This can’t be a simple referral, but in the office, this means either you’re in their office working, or maybe they come to your office, realize that a lot of nurse practitioners, CNS and others are traveling. Maybe they come to your office one or two days a week. This might be helpful, but this is certainly a benefit for someone working in a larger medical clinic.

In fact, this might be an opportunity for someone that goes into a medical practice that does geriatric medicine to deal with low back pain and pain management. So certainly something to think of it. But bottom line. You’re going to be working for this medical provider. Now keep in mind, working for them could be under two ways.

It could be as an independent contractor. It also could be as an employee. So either way it is certainly possible. But again, you can see the limitations here. It has to be done directly under supervise. Now you may wonder, well, what does Medicare pay? So what I’ve done is I’ve just put up a few areas of Medicare payments and you all notice this increased about 10% this year.

So a nice little jump for us, of course, that also helps for the VA as well, but notice in all areas, whether I’m using California, Illinois, Florida, Texas, you’ll notice the first set is generally around $40 or higher, maybe up to 45, the additional sets in the 30 range. So I’m just going to round up. 44 first set 30 for additional sets, which means approximately a hundred plus per visit because generally you’re going to do three sets and I’m not saying always, but generally that’s what Medicare loss, that means a hundred dollars a visit that certainly can be pretty good.

We’ll talk more about that, that money part of it towards the end, but I think this is something viable. If you’re getting a hundred percent. This certainly makes a lot of sense. Now it’ll make the most sense when we can directly. Cause now if you’re working with someone, obviously that a hundred dollars per visit has to be split between two.

So therefore it may not be quite that you’re getting that full amount, but again, this is not. So again about 41st set, 30 for additional sets. Now you’ll notice if you’re doing an electroacupuncture it’s more like 50 and 40. So now we’re looking at probably about 130. If you’re doing a electroacupuncture, by the way, these fees also will apply to VA, but also the.

To Medicare advantage, which I’ll demonstrate in just a second, but here’s what you’ve probably all been noticing. The Medicare advantage is an area that I certainly would say you should be looking into. Medicare may have some limits because of the way we can access the patient Medicare managers. Aren’t that complicated.

Here’s what I took literally off of my television, where they are using acupuncture to advertise this plan. And I’ve seen this over and over notice here. Zero copay. In other words, a patient comes in and they pay nothing. Now with these types of plans, you’re generally going to have to be in network and, or be a deemed provider, which I’ll explain in a moment.

But bottom line is these are going to pay approximately the same and in many instances more, which is not bad. So when a patient has a Medicare advantage plan, this is what you’ll see. They won’t have that traditional Medicare card, but one like this and you’ll notice it literally will say. Medicare advantage right on the card or Medicare part C.

So that’s how you’ll know. Be careful though, the person will still have their old Medicare card. So always ask them, let me have all of your Medicare and all of your insurance cards so you can verify. Cause once they have this plan, they no longer actually have traditional Medicare. They have this plan they’ve traded for it.

And to give you the numbers, there’s about 63 million people with Medicare. That’s a lot. And about half of them now have Medicare advantage plans simply because the benefits with them are often a little bit better, less out of pocket. And yet what’s interesting. How has it, can Medicare advantage plans offer so much?

Yeah, it’s from a plan that Medicare is paying them 600 a month. And again, I go back to, it shows how much insurance companies profit off of others, if they could take the sickest people. So here’s an actual card for a Medicare advantage plan. And this is one that was sent to me. A member of the network was saying, Hey Sam, what does it mean in this Medicare advantage of place?

The Medicare limiting charges, and often that’s misunderstood because acupuncturist aren’t part of Medicare. So you’ve never heard the term limiting charge. Medicare has fees that are called par non-par. The limiting charge is literally 15% higher than the regular rate. So you remember those fees, I just showed you add 15% to that.

So let’s talk now, probably with these closer to $50 for first set. So I want to make sure when you’re billing these Medicare advantage plans, don’t build what you think they’re going to cover bill your normal fee, bill, your 60 or 70. If they allow 50, they’ll pay it. But if you bill thinking, they’re only going to pay you 42.

And you go 42. Well, sure. They’re going to pay you 42, but what if they would’ve been paying you 50? So always bill your regular rate, just know that you cannot collect the difference. And this is what brings up this term deemed provider. Many times when you get into these plans, you may have to join, but often you’ve done.

All you have to do is accept the patient. But when you do accept the patient, it’s like you become in network on a claim by claim basis. In other words, we call it deemed D E M Dean to provider. And what this refers to is this, when you take the patient, then you have to accept what the plan allows. For your billing.

So in other words, if there’s a zero copay, the patient has a zero co-pay except the plant, or if there’s a small copay. Now these benefits actually are pretty darn good. As you can tell what the limiting charge add 15% to what I just said, and you can go, wow, wait a minute. Now, Sam, are you meaning $115 just for acupuncture?

Yeah, that’s exactly what I mean. Now these advantage plans are pretty good and advantage plan has to do exactly the same. As regular Medicare. So it has to cover just like it does here. What is covered the chronic back pain. But most of these plans you’ll notice here. It says acupuncture routine. You can find a net that you can find a network care provider, you know, searching for the acupuncture benefits, online directory.

So what are they looking for? This routine acupuncture. What is routine acupuncture? Routine acupuncture means they cover for pain management, no need for a referral or anything. Notice regular Medicare says they may require a referral or working directly. So I had someone last week contact me and say, Hey Sam, I heard they’re going to implement a referral.

No, no, no, no. For regular Medicare. Cause you have to be under super. But for these plans, you don’t require referrals for routine acupuncture, which means basically pain management, the same you’ll build any United health care plan to illustrate that. Take a look at how they cover it. This is the Medicare advantage plan for acupuncture.

Notice it actually covers dry needling. If you choose to do that, now I’m going to suspect, do acupuncture because that’s what you are. It pays. In addition, you can’t combine dry needling with acupuncture anyway, but notice what they cover here. It’s noting routine acupuncture codes, not a complete list. So what I want to highlight Medicare advantage plans, cover acupuncture, but also covered.

Exams and therapies, because notice it’s not a complete list. It lists the ENM codes and acupuncture codes, and then notice therapies, electric stem, infrared ultrasound exercise. It could include massage and manual therapy always think of what is within your scope. And they will. I have some offices doing some very aggressive care with this.

And while I think it’s a lot for one visit, I have one office that bills well close to $400 per visit. And he literally gets paid almost all of it under this type of plan. Now these are patients that a lot of pain and a lot of things going on, but again, pretty good. So a Medicare advantage plan is something I would probably say I’d want to be part of, because look at the access that they have, the key.

Do people know that you’re willing to take these plans? Are they aware of it? Have you joined any of them? Because to me there’s no downside. If you join a Medicare advantage plan, is there any cost? No. If you join a Medicare advantage plan, does that mean you have to join the regular plans with them?

Generally not. You can join just for Medicare advantage, which means the only downside is you join and you don’t get a patient, but assuming you get one or two more people are looking for a thing of how many people have pain over age 65. I mean, that’s almost a given for many, let’s learn to manage that so that they can start to do it without medication.

So I want to make sure you always are up to date. The American Acupuncture Council Network is always updating information. If you’re not familiar with our website, please go to our website. It’s AAC info network, nothing insurance, but info network. And you’ll notice here we put out newsletters. And one of the things we just put out Aetna is.

Acupuncture to all of their commercial plans now. So that’s a really good benefit, but how would you be aware of it without going to our new section? We want to make sure you’re always up to date. So anytime something’s changing, we’re the resource. Just go to our new section. There’s no cost for it. Just go to the new section and click on it.

Take a look once a week, sign up for our email alert and you’ll get that as well. We also posted out on our social media, in addition though, notice here about how to deal with financial agreements. Remember we did the no surprise, not that long ago. So we’re going to be a resource. Allow me to be part of your practice.

We have a hotline service where you can call me, email me, fax me on any type of information you need questions with. We’re here to help you get paid. We have a vested interest. We want your success. I do because I really want to, before I retire, making sure acupuncture is fully integrated into Medicare.

So take a look at our hotline and we’re always going to be a resource with you. The American Acupuncture Council Network, go to our site. Give us a call. We’re here. I’m going to say, thank you everyone very much. We’re going to have a special Friday show and the guests, the guest hosts will be Shelly Goldstein.

And I’m gonna say to all of you be well, take care of yourself. Remember you’re important, but it’s more important to be good. Thanks everyone.


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No Surprise Billing in the Acupuncture Setting


So today’s program is going to hit a chord. I think for many of you, because you’ve probably heard a lot about this and you aren’t yet. Does it apply to me? Does it not apply? Does it really matter? And of course it does. But we have to make sure that we don’t create something where we’re creating too much emphasis on one thing and not understanding the big picture.

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, your coding and billing expert for acupuncture, the American Acupuncture Council Network and the American Acupuncture Council malpractice carrier. With another episode of, to the point to make sure your practice continues to grow and thrive and understand what’s changing and updating to make sure you’re always having the best success that you can have.

So today’s program is going to hit a chord. I think for many of you, because you’ve probably heard a lot about this and you aren’t yet. Does it apply to me? Does it not apply? Does it really matter? And of course it does. But we have to make sure that we don’t create something where we’re creating too much emphasis on one thing and not understanding the big picture.

And that of course is the no surprises act. So please let’s go to the slides. Everyone. Let’s take a look at what’s going on with this no surprises act. This has actually been something that’s been out for a while. It just became implemented January 1st. And really what it’s intended to do is to protect patients from an unexpected or undisclosed medical bills.

And I want you to think of the big picture. Think of how many times you’ve heard of this. That’s gone to a hospital when they’re there. Maybe they get a surgery and it turns out the anesthesiologist is not in their network. And lo and behold, now they get this bill out of network for thousands of dollars.

They had no idea. That’s really the onus behind this. So again, I always report to you to take a look. There’s my name, there’s our website and my email to make sure you’ve got all the right information. But here’s what I want bust. The hyperbole, you’ve all been exposed to this. And if you’re using Dr.

Google, you’ve probably been exposed to it. People love to put out stuff and not really understand it. Think of all the different things you’ve heard about vaccines that turned out to not be true as far as mandate. The other thing about this is the same thing with the no surprises act. And I always say be careful, gave away the exaggerations of a hyperbole.

And I would say use something that’s called Aquaman’s re. If you’ve never heard of that concept that often says that there are very complex questions and often the best answer is the simplest. And I’ll say, this is no different. So starting January 1st, this no surprises act was designed to protect individuals from very high out of network bills or just high bills without them being aware of it.

That’s all this is about. So you have to think from an acupuncture standpoint, aren’t you probably doing all this. Chances are you are cause aren’t you already doing some type of financial agreement with your patient. So this is essentially the design, these big bills. The law requires that providers give a good faith estimate.

You’ll hear this term. It’s an estimate. I probably don’t think in some cases you’re going to be able to give an exact, but at least a range, by the way, that range could be within $400. So you can imagine how many of you have a visit? That’s 400. So I don’t think it’s going to really fall outside of that, but I want to think of just what’s better for us is to make sure patients understand what’s going on.

Obviously, there’s going to be two things that are a barrier or a patient coming for care. Number one, they don’t know about what you do or afraid of it. Unknowing. Isn’t going to work, but number two is cost. And so the better we are at aligning what our costs are in the patient, understand that the better off we’re going to be.

So if you think of it, aren’t you already doing a financial agreement, making the patients aware of what your charges are and what their out of network or excuse me, out of pocket costs might be whether you’re in or out of network. So what I’ll say to most of you. Chances are you are already doing all the things you need to do for the no surprises act albeit maybe a little bit differently, but for the most part already accomplishing that.

So who has to do this? The, who is people with health insurance, many of your patients, whether they use insurance or not, or pay cash, we have to make them aware. So if they’re using your health insurance for. Or not, it’s simply making sure a patient’s aware of what are the expectations of costs. And this is where things can get a little tricky because if you’re in network or out of network, that’s certainly can make a big difference.

So here’s what I, to suspect that you’re doing at our hope you’re doing how about some simple language in a financial agreement that something like. Many insurance policies do cover acupuncture care, but this office makes no representation that yours does. We’re never promising think of a medical office.

They never tell you, we guarantee your insurance is going to cover, or that we take it. They’re saying that we will take some or offer it. And it says here insurance policies may vary greatly in terms of deductible and percentage of coverage. You’ve seen. Yeah, the plan says it pays 80%, but of course, 80% of what, not necessarily what you’ve built.

So here’s what we tell them because of the variance from one insurance policy to another, we require that you, the patient be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. And we’ll do our best to verify your insurance and bill in a timely manner.

But ultimately let’s always remember who is the contract, really with an insurance it’s between the patient. And the insurance company. Not necessarily the doctor and Lusher and network. So you want to be very clear if you’re out of network, we want to be clear as to what your charges are because the insurance is going to pay.

Some of it. Patient pays the rest. When you’re in network may be a little easier, but obviously you’re getting less money. What if you have a $10 copay? That would be pretty strictly. So we have to do it for the patients, give them information, but who else? Us as providers, we give that information and we have to make sure we understand our differences.

When we are in network, it’s mostly a fixed co-pay and we’re going to write off by example, let’s say you’re billing an American specialty health plan, and maybe the patient has a $20 deductible, or excuse me, a $20 copay. That’s automatically what they’re going to pay. Other stuff is written off. You remember, regardless of what you do, right?

You could do lots of services, but they’re going to include just that fixed per diem price. So it’s very, in fact, straightforward. This is what the patient will pay. This is what we get now, conversely, where it gets a little bit more complicated though, is what about out of network? And this is what I want to warn you is that so many offices do this improperly.

You’re probably setting yourself up for something that they would consider anti-kickback or a kickback as well as a false claim when you’re out of network and building insured. The patient has to pay what the insurance didn’t pay. We often use the term co-insurance because co-pay, we generally mean a fixed amount.

Co-insurance we mean, what is leftover? So here there’s no contractual write-off so let’s take an example. We build an in-network plan, a hundred dollars, but because we’re in network, that patient has a $10 copay and the insurance pays $40. So we collect 50 with $50 being written off because we have a contract with that.

Now let’s take another patient. We’re out of network. We build the same $100. The plan let’s say still pays $40. Great. It pays 40, but now because we build a hundred we’re to collect $60 and I know many of you go no, I don’t collect that. I’ll write it off. There’s the kickback you’re giving the patient again.

Of $60. They didn’t pay. Cause why are they not paying what others have to pay? So in other words, you can’t have it just because your insurance is not as good. You pay less unless you’re in network. So if no contractual, write-offs kind of what you, bill is what you have to collect. So be careful of that being a kickback, like by example, if you just told a patient, oh, you have a deductible, no big deal.

I won’t collect it. That’s a gift. And we can’t give gifts for a patient for, to become a patient with us. So I will always come back to say, if you’re willing to build it, you have to be willing to collect it. So be careful of setting your fees off of your best paying insurance or your worse, because if you have one insurance paying that much, what about the patients that doesn’t, they have to pay the difference, which means for many of you, if you’re doing that, you might as well join and be in that.

Because you’re writing it off anyway, you might as well do it legal. So here’s the difference. We have to make the patients aware of that. So as the provider, we have to do to make sure they’re aware of what those amounts are. Don’t overcomplicate it, but it’s really just the out of network of the patient.

Now, if you’re in network fairly simple, because you just telling them what that price is, and I’ll give you some examples of what these forms might look like. But what I want you to keep in mind is what you’re charging. You have to be able to make sure patients understand those. Maybe what their insurance might pay at least a portion, and then they’re going to pay the balance.

So if I’m billing $400 per visit, I can’t guarantee what the insurance is going to cover. Do I have to make the patient aware they could be liable for $400? They couldn’t be. So again, be careful don’t set your fees off of your highest. Now who else has to deal with this? It’s not just us or the patient, but the insurance company, the payer, and here’s some really good rules that they have to follow that I’m sure some of you have run into problems with.

They have to verify who’s in and out of network. How many times have you seen someone coming to your office to say, oh, I found your name on my network and it’s something you dropped out of months ago or years ago. So now they have a duty to make sure that list is updated every 90 days. And it has to be updated within two days of notice, which means many of you are going to get an additional request from insurance companies very regularly, probably every three months to make sure you’re still willing to be in network because those lists have to be up to date because if the insurance company improperly puts your name on that list and that patient comes in the patient, won’t be liable to you.

But, That insurance company, because your name was on the list. They misinformed the patient. So it puts a lot back onto that insurance company, which I liked because how often are we left on the side when we’ve dropped out or we’re not part of it. And yet they try to say that we are, it also emphasizes this, that insurance companies have to be more transparent as the amount that they’re going to allow her pay.

How frustrating is it? You bill 75, 1 insurance pays 41 pays 30, maybe one pays the full 75. How do we know that? Partly once you, bill, you can obviously keep a log of what different plans pay, but otherwise the first time [00:10:00] out, how would you know? And so this is where you have to warn the patient, that I cannot guarantee what your insurance is going to cover.

You can certainly estimate it, but you’re not guaranteed. So potentially they can, oh, the entire amount. Now insurance companies should be more transparent to give that information. There should be more access to online portals or information about what they allow. I would even in fact, have the patient call and say, what do you allow for acupuncture blue cross blue shield of Illinois through their Availity platform.

And I’m sure others are going to follow the same thing. There’s a tool available. If you’re a network you can plug in your codes and your. They’ll tell you what they allow that way. There’s going to be no guessing. What’s there now. Bear in mind. If you go back to ELBs, you’ve received, it’s probably easy to figure out what’s been paid, but it’d be nice to really more real world information about what they’re allowing get rid of that mystery.

Why is there always a mystery of what they’re willing to do all. For the payers, there’s going to be a way to dispute. So it says here out of network physicians, [00:11:00] clinicians, and facilities, wherever process, available to challenge inadequate out of network payment. So you ever seen this ridiculousness, you are billing a fee that everyone pays you and all of a sudden this insurance says, oh no, the usual customary for your.

Is 50% below that. Wait a minute. What means that they can do that? If they’re charging, what is fair and reasonable now, again, if you’re in network, they can make that provision, but out of network, no. So there’s going to be an independent dispute resolution and independent body that will oversee that.

And I think is going to make this a little bit more reasonable that these companies can’t come out and just say this is what we’re going to pay. Take it over. Unless you’re a network. So it gives a little more power for us and the patients to push back on some of these ridiculous low fees that they allow.

So in summary, here’s what I want you to do. Establish a fair and reasonable fees schedule. I did a program about, oh, just right before December, about how to use RV use, but I’m going to. Hire me as an expert, we have a service called the network at the American acupuncture council network, where I [00:12:00] help you just with that to make sure your fees are in line out guarantee.

Most of you have 50% of your codes that are probably not correct. So let’s establish a fair and. Clarify who you are or not in network with them. When people come in, you can be upfront with them. I don’t belong to Aetna, but I do belong to blue cross. Maybe in addition, disclose your fees. Now, what you can do is you can put a big list of all your codes and fees, but that doesn’t really help because that’s not what the patient is getting.

So you want to do something that identifies with this patient is receiving so they know what they’re paying. Can you imagine if you just went to a hospital? And they had a big charge list of everything they might do. How would you figure out what you’re getting done? So you want to be more specific? So the patient has a good choice to know.

Oh, okay, great. I’m going to get this care because I know I can afford it or I will pay for it or here’s what I would rather do. I would rather not treat someone and not get paid, then treat them and not get them. You get my point. That’s happened to all of us at some time, be clear with their [00:13:00] out-of-pockets eight or out of network with a financial understanding or agreement that way.

No, one’s had a mystery and you’re thinking we’ll see them. This no surprise act is what I’ve already done is try to give a patient information about what their costs are. That’s exactly what. What I will say, avoid the hyperbole of when people get all excited, you gotta do new forms. You gotta do this and that.

No, don’t post it on your website. You don’t know what they’re coming in for. Wait until they’re there and use something like this. So you notice this is a simple form that just goes into the same thing. I said, many insurance policies do cover acupuncture, but take a look at where the blue arrow is. It says our services may not be covered by insurance.

Our office and providers are not in network with any insurance. And do not accept insurance assignments, meaning we’re expecting you to pay up bill your own insurance, or you wait for the check. You will be billed the cost for your care and will be responsible for that amount and any difference that the insurance pays great, but that’s not going to be on.

We then indicated in red that the patient says, I [00:14:00] understand, and I will have the financial responsibility applicable to healthcare services provided by an out of network provider. Remember, don’t make them think that you’re in network when you’re out. And then a breakdown here are the services that are going to provide.

Now you notice I made a little spreadsheet here of common services. You might just have something you just fill in the. Of what you’re doing and the fee is, so that way they could know and notice I put an estimated payment. Yep. But is that something you’re going to absolutely guarantee?

No, it’s an estimate. And remember you have a $400 threshold, so it’s pretty easy for us. So the big picture for me is I want a person to be comfortable with their care that they can afford it and remember affording it is not always as complicated. Think of this. How many times have you seen a car that they advertise on TV?

Do they ever tell you the total price of the car? They never do. They always say, oh, it’s 4 99 a month. So here, we’re going to do the same thing. We’re going to tell them what the total fee is. And if that’s something that kind of rebuffs them, then you can talk to them about, Hey, no problem. We work out payment schedules for you.

We’ll debit your card. [00:15:00] Anything to just make it more palatable, but at least this way, no, one’s going to be surprised by how much. So this would be a good way of dealing with when you’re out of network, which frankly, I recommend now, what if you are in network though, here’s a different. It says here the same thing at the top, we’re going to bill, but notice it says our office and providers are in network with your insurance and put the client name.

We then talk about balance billing, which there’s none. So that’s why in the red section, you’ll notice it specifically talks about copay, which is fixed and maybe what’s excluded by example, many of you who belong to American specialty health, you understand that they do not cover massage or manual therapy.

So as a consequence, you can inform the patient that’s not a covered by. And they would be liable for those amounts, but you have to tell them beforehand. So do be conscientious of making sure when you’re making these types of estimates, that patients are clearly aware of what they’re going to pay.

That’s all there is to it. Is that really that complicated? I don’t think so. It’s just a matter of thinking just like yourself as a. What would you want [00:16:00] to know what the costs are that way, how you can afford it? And if you feel it’s unaffordable, now we, as providers can work out something for them to do that.

Now, if you’ve never noticed, if you go to our website, the American acupuncture council network, you’ll notice we have a new section. Have you ever been there? Have you seen all the information about. We’re putting out information on vaccine mandates, whether it is or isn’t no, it’s different a little bit for each state, not ma not nationally, but notice about four weeks ago, we put things up on the no surprise billing.

So one of the ways you can always get engaged and we’re here to help is by just going to our news. Our goal is to make sure you have a practice that is thriving, that’s doing better. How do you do that by having the correct information to make sure you’re getting paid? That’s our ultimate goal. So if you really want some day to day help, we offer a service, we call our network or hotline where literally you hire me as part of your staff or part of your.

And then you work with me directly by phone fax, email, even zoom, all types of issues, anything coding, billing, [00:17:00] documentation. We’re always here to help you. The American acupuncture council network. Here’s our site and our phone number. If you have any questions or concerns that never be afraid to reach out to us, we are your teammate and we want to make sure you’re doing well.

So I wish you all the best now coming up next week for the live program will be Jeff Grossman. I look forward to seeing you all at a future seminar until. Be well, take care of yourself. Take care of your family. Thank you everyone. Okay.


CollinsHDAAC12082021 Thumb

New Year, New Fees?



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, your coding and billing expert for acupuncture, the American Acupuncture Council. And of course for you giving you another episode with, to the point from the American Acupuncture Council and malpractice carrier on keeping you up to date, what’s changing. What’s new as the coding and billing expert always want to make.

You’re on top of everything that’s going on and what the changes are going to be for next year. So let’s get started with understanding fees. So let’s go to the slides, what I want to make sure there’s a good understanding of is how do I determine fees? And so you’re going to see what I have here, the RVU update, which stands for relative value units and how that affects your fee schedule, what changes you can make at the beginning of the.

And how your fees are going to be paid. Well, let’s talk about what are our fees. When you hear this term, you see our, or usual customary and reasonable, what does that mean? Well, it’s the amount that’s paid for medical services based on your geographic area. In other words, what is usually in customarily pay kind of like houses, what’s the usual and customary for your neighborhood.

It’s based on what the houses sell for. So in that sense, that’s usually the fee that’s charged for a doctor for a service and falls within the rains that others charge within the area. It is a service deemed necessary to their current condition. But what is the usual fee? Now keep in mind that usual fee has some variances.

Are you on the upper end or Lauren? I hope that we’re somewhere in the middle because here’s my concern. Let’s say you’re charging $50 for a service. That someone, including insurance companies are willing to pay $75 for if you’re only billing it at 50, of course, what are they going to pay you 50, even though they would pay at 75.

So I want to give you some tools that help you to establish a better way of understanding your fee. What let’s understand, what is the model we deal with? There’s a course in the insurance model. And that’s the reasonable customer feed that insurance has say are the acceptable range. And of course there’s a lot of variation to that.

And of course, as you can expect, if you belong to an insurance, like say you joined blue cross or blue shield or Ash, that’s going to be a set fee, which is probably not usual and customary, but the trade-off is I joined. And hopefully you get more patients, but you take far less money, not something we’re really that tickled with and less volume can be there.

So I look at it more from the patient value. What is the service worth that a patient is willing to pay for? And this is where we have to provide the value of the service. So someone’s willing to pay. And I think this is the model that acupuncture really thrives in the American physical therapy association has indicated that they find that as soon as people have a $30.

They start losing about a third of their patients. Do you know that’s not true for acupuncturists? So I’m always a little nervous that we sometimes undercharged for what we’re doing, because we’re afraid of that amount being something that’s going to scare the patient off, but what you have to think of, what’s the value and want you to think of as an acupuncturist, think of the value for a moment.

How many of you have been to a medical. And when you went in, you’re in pain and when you left, you felt better. And I’m not saying this as a negative in a way against medical doctors, but that’s not the way they treat. Think of how many times you have a patient come in. Maybe they have a headache or back pain, and they’re not even sure acupuncture is going to work.

But then after the visit, they’re like, oh my God, I can’t believe I’m not in pain. I’m 50% better than. There’s a lot of value there. So I want us to start to think of the value of the service and how we establish rates and using something called the relative value units. The relative value unit is a value determined actually by the federal government on the cost of each medical service.

Every CPT code has a relative value. Now what this relative value does, it allows you to compare the value of one service to another. So by example, if there’s a service that has a value of one. And another service that has a value of two. That would mean that service that’s a value of two would be twice the cost.

And so one of the things I want to do with this is take the RV use to help us begin, to establish a reasonable fee for the services we provide. The development of this started way back in the eighties and Harvard, and it continues to be updated every year by CMS. In fact, it is updated already for 2022, and I’ll give you a preview of that coming up.

So here’s what I’d like. You all to do. Take a moment. And tell me, what is your fee for these four codes now, obviously you don’t have to tell me, but I’d like you to think or write them down. What do I charge for the first set of manual acupuncture? What’s my fee for the second set or additional set. How about a mid-level new patient exam?

What do you charge for that? And then what do you charge for massage? What I’m trying to point out is if I can tell you the value of any one of these servers. Based on the relative value. I can tell you what the value is for another. In fact, that’s how insurance companies decide to pay for certain services is based on the relative value of each.

So let’s take a look at what is relative value. You’re going to see here a whole page of relative values. And I put all the common codes. If you’ve been to a seminar with me, you’ve seen this, but this is the update for 2020. What you’ll see immediately is that there’s been an increase. If you notice that I put the arrow around it, you’ll notice the relative value for now.

4 9, 7, 8 1 0 is 1.16. Whereas last year was 1.06. That’s about a 10% increase. So if someone says to you, Hey, acupuncturists are having an increase in fees. Actually that’s true. And it’s based on the relative values have been increased relative value though, just compare one service to the other. So the easiest way to think of this is if you look at the relative value of 9, 7, 8, 1 0, you notice as a value of 1.16, and then the value of 9, 7, 8 1 0 is 0.87.

Now, when you look at that, you’ll go, what does that mean, Sam? Well, I’ll make it real simple this way. What if you charge and again, this may be a little high. What if you. $116 for your first set. What would be the price of the second set? $87. That’s the idea. So if you can tell me what you charge for one code, and if that code is accepted and paid by a payer, I can tell you what they’re going to pay for everything else.

Now, the good news is you don’t really have to look at that many codes. I know this list is a little. But I want you to think of what services are you billing on a regular basis? That’s all we need to look at. Don’t worry about all of them. So how would I do this? You’re going to see her on the right. I did some calculations.

Now don’t be put off by the math part of this. It’s not complicated. All you have to do is tell me, what do you charge for 9 7, 8 1 0. So now I want you all to think of that. I asked you a moment ago. What do you charge for 9, 7, 8. You’ll notice I put a charge of 65. Now you might say, well, Sam, how’d you come up with 65.

I’m just saying that’s a typical fee for a lot of acupuncturist for the first set. So let’s just say 65 was your fear is your fee to figure out the fee for every other service you don’t guess and go, well, I guess I’ll charge $10 less. Here’s what we do. We take our. And we divide it by the services relative value.

So you’ll notice that I take 65 divided by 1.16, and it gives me 56 0 3. Now 5,603 is actually not the price of something. It’s the conversion. I then take that number and take any other codes relative value. Multiply to tell me the fee of that service. So by example, you’ll notice here 9, 7, 8 1 1 has a value of 0.8, seven.

So I’d take 56 0 3 times 0.87. It gives me 48 75. So that means if my price for a 9 8 9 7 8 1 0 is 65. What should be my price for a 9 7 8 1 1? Well, I would round up to 49, but I think you get my point that way you make sure you’re not cheating yourself. And I’ve seen a lot of providers do this. They’ll build a first set of 60.

And the second set of 50, 65. Now, of course, that’s your option. You can do that, but he won’t be my concern. What if the insurance company pays you in full for the second set? What does that tell you? You’ve done with the primary code you’re billing way below. So I can do this backwards as well. If they allow 65 for the one, one, I do the same calculation the other way, and I do it the same for every service.

So think of it in simplest terms, the difference between the first set and the second set is about 30%. So if your first sets a hundred seconds, that would be 70 or in this case 65 to 48, 75 or 49. Well, the same applies with any of their code. Like you might say, well, what do I charge? Or what should I charge for an exam?

Well, you notice the relative value for 9, 9, 2 0 3 is 3.2. So I take 56 0 3 times 3.29, and it gives me 180 4 33. Now the reality here is if you look at 1.16 to 3.29, it’s not quite three times the amount, but you can see it’s pretty close. So really what you want to think of is that the price of. Exam should be three times the price of your acupuncture service based on the relative value of the service.

Now, how these relative values work, they determined that the amount of work that’s involved with each service, and that includes not only the work involved with the service, but the type of provider, what your malpractice costs are and so forth. So again, 180 4, based on a $65 price or about three times the amount would be pretty reasonable.

Well, what about other services? Have you ever built, you know, let’s say. How would I figure out my price for massage? Well, massage value now is 0.8, eight. So I’d take 56 0 3 times 0.88, and gives me 49 30. What I want to make sure is that my prices for my services match each other. I’ve seen offices, bill out some pretty large amounts for one code at a very low amount for the other code.

And my question is why are you doing. What was the purpose? Now, if you can say to me, well, Sam, I did that because I just don’t want to charge my patients as much. And you have a good reason, I’ll say, okay, because maybe that fits your neighborhood, but if you’re doing it because you don’t know, like by example, what if you charge 50, 65 for the first set and you charge only $30 for massage?

Well, you. But if someone’s willing to pay 65 for a first set based on relative value the exam, or excuse me, the price for massage would be about 50. So start to really go through these coasts and start to see that. And here’s the beauty. It increased for acupuncture. So, I’m not sure you’ve heard this or not yet, but the prices for acupuncture related to rates associated with Medicare rates, or anyone will go up next year.

Now let’s not get too excited. The rate increase is about six to 7%, but that’s well above cost of living. So, yay. Finally, we’ve got an increase. Do you know? No other profession got an increase. If you go through all the fees, actually chiropractors, medical doctors, physical therapists, all got about a three to 4% return.

Acupuncture got a 6% increase. And I think mostly because the relative values are becoming more apparent. So you’ll notice the relative value for 2021 was quite a bit less now, 1 0 6 to 1.16, you think? Well that’s 10%. Oh, no. Because remember that’s again, already up at that level. So again, probably about six or 7% to give an example of what I’d like you to do though.

Now, if you’ve been to a seminar with me, you’ve seen this RVU sheet and if you’ve never been come to a seminar or join our network, so you can get this type of information, but here’s what I’d like you to do. You don’t need to do every code, but start coming up with a competent, reasonable fee schedule.

Cause I don’t want you to. But I certainly don’t want you to undercharge. And what I find for most offices, frankly, you bill about five or six services regularly. And I would say the average acupuncturist has three to four of those that have the wrong value, which means 50% or more of the code you bill are undervalued, which means you’re just losing 50% of your income.

So what I’d like you to do is go through, do this for your ENM codes and not every code you don’t bill, all of them, acupuncture codes, probably heat like infrared or other ones. Bodyworker massage, pretty typical as well. And maybe a little bit of exercise. Now you might say, well, Hey Sam, I do some other services.

Fine. Do those as well, but realize you’re not going to do a bunch of these. And what I would like you to do with this is begin to break down the cost. So here’s an example, and this is just for California, Southern California, specifically for Los Angeles and orange county. Now this is something we do for our network members in seminar attendees every year is we give you the updated.

For Medicare, which of course means the VA. And you’ll notice there’s been an increase notice 9, 7, 8 1 0 last year was $40 and 7 cents. Now it’s 42 67. Now, is that enough to go? Oh my God, we’ve got a lot more money. No, but a 6% increase if you’re generating a hundred thousand dollars a year. Just on acupuncture codes.

That should be an additional 6,000. So you can see here a nice little jump. Now, remember these are just for the California rates. Every state, every county has their own rates. And again, if you’re a network member with me, or if you’re coming to an upcoming seminar, you will have access to all these. So, you know, the rates that way, you’re making sure that you’re getting paid the right amounts, because my concern is, if you build below these rates, what are they.

That rate. So you want to start to understand what is the value of my service, but let’s go beyond that a little bit. Here’s what I’d really like. You all to do, take a moment to create a spreadsheet, like what you’re seeing here. And you’ll notice what I’ve done is I just put some common codes for acupuncture from exams, through acupuncture, massage.

What I do with one column is put the RV use and then maybe the next column might be what’s your time of service discount. Maybe that’s your price for cash, you know, maybe. You know, five or 10% below what you normally bill, but then you have your regular rate, just regular. What I, bill insurance then of course, what I’d like you to do is go through from payers that have paid you in the last six months or a year and put down those amounts.

What does Aetna pay? Blue cross blue shield. Cigna. I guarantee you all have that. One of the things I do with network members is to go through this and say, Hey, look, let’s start creating a competent sheet. The realization. You don’t bill as many codes as you think. So you don’t have to do a lot, but go through that way.

But what if it isn’t a patient comes to you and they ask you because of course the next year we have the no surprise billing. Okay. What does my plan pay? Well, you can go to your chart and go, oh, your plan is going to pay XYZ dollars. And this is going to be your balance. What it also does though. It’s a chance for you to look to go, which of these are good or bad because as your practice begins to go into next year, what is your plan?

To really begin to maximize your office. One of the plans I would do is let’s do a survey of what is the better paying plans that we may deal with and how much are they paying now? By example, Medicare work comp are all standard fees. Most states have standard fees for that. So you can already put that in and at the very least I’d want you doing that.

So here’s an example with RV use. You can do a lot to determine your care. So by example, if you’re in the state of. The work comp rate in Texas, what they do is take this value 61 17 and they multiplied by any RVU. So by example, I can tell you exactly what the fee is for work comp in Texas for 9 7, 8 1 6.

Remember, it’s 1.16. So it’s 16% above this, or roughly close to about 67, maybe $68. Or how about if you’re in the state of Utah? What they do is use a conversion, but two different ones. If it’s an ENM code, they convert with a 56 conversion or 52 for other codes. So realize that the Medicare conversion is roughly $37 plus or minus depending on your county.

So that would be a starting point. And I’ll give an example. What if you’re admitted? If you’re in Michigan, what they do is they just simply take whatever the Medicare rates are and double them when it comes to personal injury. Now, one thing to be concerned with here is if you just double your rates on personal injury, that’s good because personal injury will pay you.

But what if you charge your other patients less? Remember you can have two different fees. So you’ve got to make a decision, even though I can charge double for personal injury. If you’re charging maybe only 1.5, that’s what you’re going to charge for them. What my suggestion is. Probably be at least 1.25 to 1.5 above Medicare rates.

Notice by example, the Medicare rates in for work comp in Michigan, they just take a conversion of 47 66. So this is where using RV use will help you. But take a look at this one. If you have a patient that’s with Boeing and particularly Boeing uses, and they’re employed with Boeing they’re blue cross blue shield, they sent a directive out this year.

What they pay is 175% of. So what if you got 90% of your patients with this plan and you’re billing a hundred percent of Medicare, you’re losing 75% of your money. Now keep in mind, maybe you don’t want to charge 175% because you still have a lot of patients that can’t afford that. So it’s going to balance somewhere, but my concern is, am I setting my fees off of my best insurance or best richest patients?

Or am I sending it off of my port? So I want to be somewhere in the middle there, but what I want more than anything is a competent fee schedule. If someone says, how did you determine your fees? You’re going to say, I use relative values to determine the value of my service. Tell me what an insurance will pay for one code, and I’ll tell you what they’ll pay for any other code, because relative values goes across the board.

As you can see here, by example in California, we’re comp is 1.2. And so simple way of looking Pennsylvania, 113% Florida, 200% for work comp. So lots of changes here that allows you to start to use this as a way to competently set up a fee schedule. And I’m going to suggest it’s the new year. Let’s start looking towards that.

Obviously, if you’re dealing with a VA patient, you’re going to get an automatic raise, but what if you don’t raise your rates? So what if you bill at last year’s rates, what are they going to pay you for next year? So you’ve got to make sure to bill the higher rate or bill your normal rate to make sure you’re getting the maximum amount out of it.

So here’s something I want to make sure everyone’s aware of. Do you know when we posted this, if you’re a member with us, you received an email on this Medicare fees. The deductible acupuncture fees increased six to 7%. Really good notice we posted this a month ago or thereabout. If you’ve not already go to the American acupuncture council network, Facebook.

And take a look at our Facebook page or in our site, just click on the new section. We update you there all types of things. The American acupuncture council wants to be your resource. We want to make sure that your claims get paid, because if you’re not getting. You don’t need our services. So frankly, we’re symbiotic.

We have to do a good job of helping you to make sure you have claims. We also offer a service. We call the network, take a look at our site, come to a seminar, be informed about information that’s coming out for you. Cause if you’re not informed about. You’re probably left behind. Take a look. We’ve got lots of live, meaning in-person seminars, upcoming, but also virtual.

So just pick the date that fits best for you because we have a vested interest in you. We want you to do well. That’s what we always give you this information. So I’m going to say thank you very much. Next week’s hosts are going to be Dr. Jeffrey Grossman. I wish you all a very good new year in a Merry Christmas, but also let’s plan and have a good prosperous 2022 see you next time.


Sam Collins for AAC02102021

Do Not Risk Loss of Payment! – AAC Infonetwork



I want to talk to you a little bit about what’s been going on and I’m sure many of you have noticed on what’s called the medically unlikely edits or the limits to care. And I’m sure some of you have seen it.

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 Samuel Collins, the coding and billing expert for acupuncture and the American Acupuncture Council. But most importantly, the coding and billing expert for you. While I do have roles with the world health organization, United healthcare and Optum health. My ultimate goal is for the practitioners just as American Acupuncture Council is, and this is another addition to make sure that you’re getting things right, understanding what’s going on, promoting your practice. And I do the billing side I’m with the American Acupuncture Council Network, which means we’re part of the malpractice side that really helps you with the coding, the billing, the education and seminars we’re here today. I want to talk to you a little bit about what’s been going on and I’m sure many of you have noticed on what’s called the medically unlikely edits or the limits to care. And I’m sure some of you have seen it.

Hey, why are they denying? In fact, we’re running into some areas in New York where they’re paying only for one, which actually shouldn’t be what’s there others paying for two or three? Well, what is correct? What do we have to make sure we’re doing to make sure we are getting paid fully, but also making sure if they don’t pay us, what do we do about it? And where does it come from? So let’s go to the slide. So you can start to take a look at what’s happening. So in these slides, you’ll notice I have here. It says acupuncture, medically unlikely edits. MUE is what they term it. And what that deals with is the maximum number of services that can be done per day. And that’s not just for acupuncture acts. So that includes physical medicine and other services. And also want to hit a little bit on to medical necessity, cause that’s really kind of where this dovetails.

So if you take a look here and I know this is smallest, let me enlarge this a little bit for you. You’ll notice here. This is from empire blue, cross blue shield. And notice what they’re bringing to this doctorate says the review indicated your average utilization of acupuncture sessions of one hour or greater personal one-on-one contact with a patient is higher than expected. So that means you’re doing an hour more so than everyone else. They’re not saying necessarily it’s wrong, but because it’s above average, they’re trying to figure out why. So notice in the next paragraph I highlighted it says, we are aware of many factors that may impact the coding of your acupuncture services. Our goal is to assist providers. So they’re not necessarily trying to be punitive, but trying to figure out why are you doing more is for too much, not necessarily, if you talk to most acupuncturist and I’ve taught seminars now for 23 years.

And I would say the average acupuncture is probably does between two and three sets regularly. So four is not unheard of, but it’s not typical, but I would say the average is two or three. So when it goes to four on a very regular basis, there could be some issues. In fact, this is probably where the medically unlikely edits come from. Well, let’s talk about it from a medical necessity standpoint, if you’re going to do ortho, that’s why that’s part of what we have to determine. So I’m going to give you what medical necessity is determined by the company, American specialty health, which I’m sure a lot of you have a tendency to. There’s kind of a love, hate relationship with them. I don’t think the hate is so much from the protocols is just, I wish they paid more, but ultimately I do think they make a nice protocol for what they determine as medical necessity.

So always understand when you’re going to do four sets or more, the Y has got to be based on the diagnosis. The severity of the problem. Now the difficulty with diagnosis is often the diagnosis for acupuncture is simply just pain. So how does that really demonstrate severity unless you’re coding like a lumbar disc. It really doesn’t. So remember your chart notes are going to be an important factor. The past medical history of the history, including is it traumatic? Is it repetitive? Is it acute? In other words, severity, what’s also going to be part of that though, is comorbid factors. Things that can complicate the patient, things that are underlying patients, very overweight patient has a very poor diet. Patient is diabetic. While you may not be treating those things directly, could they affect how the patient responds? Meaning why did I do four sets, other things?

They look at our range of motion, palpatory findings, orthopedic testing, neurologic testing, but they also do look at the tongue and pulse notice all these say quantify. Cause we want to know, well, if it’s severe, these things would all be more severe as evidence and quantified do. Remember they will look at the functional limitation, how the patient is getting better or not better just stating the patient feels better is not going to be enough. We have to be, how is it better? What can they do now that they couldn’t do before? And there’s always going to be goals for it. So ultimately think of medical necessity as kind of looking at how you would see a patient overall in their improvement, not just paying level. And there’s something to think of. This is from a company called health partners and I liked the way they put together the factors that they look at for medical necessity, things they put in mind.

Notice the first thing, gender fatigue, lack of energy, notice mobility, agility, strength, sleep issues, not falling asleep. You know, not waking up feeling rested or just the decreased quality of life. Those are factors that if you quantify given issue of potential severity beyond just stating pain, now I bring this up because of course, if you’re going to do acupuncture, we know that there’s four codes and you know that the four codes are there to allow us to build additional services when necessary. Some patients may get one, two, three, or four, but what’s important to remember is that acupuncture requires two things for billing purposes, for billing purposes, you’ll notice the acupuncture code says one or more needles, which means you have to insert a needle. But then it also says initial 15 minutes and each subsequent code says the same thing. It says reinsertion, which really should be additional insertion and 15 minutes.

So the codes are really going to be based on inserting needles and spending time. So if you’re telling me that you’ve done four sets, that means you actually have to be in the room with the patient for the full fifth, 60 minutes or close to it and do four distinct insertions one in the first 15, second, 15 and so on, which is not something that you wouldn’t do, but you have to document it and let’s remember, and see here. It says how the 15 minute session is defined. Remember, as soon as you walk in the room with the patient, say, Hey, how are you feeling today? The time starts, all the things you do. That’s part of your acupuncture, including review of history. Hand-washing choosing points. All of that counts. What’s important is to document it because you’re doing multiple sets. The one issue we’ve run in through the American acupuncture council is offices.

Aren’t documenting that well. So that becomes a problem. Well, it’s also a problem just based on number. So let’s take a look here and I’ll show you. This is an example of a soap note for acupuncture that has documented three sets. And I want you to see here, and I don’t want you to really comment about necessity. Just show how it works. Notice each set is identified set one, two and three. Notice the points are identified in addition, the face-to-face time from and two, or it could be minutes and then retention. So clearly when you see here, you’re noticing there is clearly three sets because there’s three separate insertions as documented notice the face-to-face time equals hitting the eight minute rule, if you will. And then it shows the separate retention. Remember don’t count retention towards the total time. So if you’re doing multiple sets, we have to make sure that we’re documenting all those factors. Because if we’re doing two, three or four, it still has to be shown. Did we do it? Well, this brings me to this kind of medically unlikely edits or what CPT does is they do edits for all types of codes. And there’s two types of edits that are common.

The first one is called the correct coding initiative at it. Yeah,

That is one that the correct coding initiative edit is one that there we go is used for coding, such for chiropractors, like a chiropractor. When they Do manipulation, there are codes that are part of manipulation That have to be separately coded. So by example, they Have to not code nine 71, four zero With manipulation. This I apologize. My phone is,

But you have someone who keeps trying to call through. So I apologize That these coding initiatives, goodness, here we go. And my apologies for this, I Cannot seem to get someone to understand what a message says. I’m not available. That I’m not Nonetheless, they kept trying let’s do this.

Okay. My falsies bear with me, correct coding initiatives. Just tell me what codes can and cannot be billed together. Okay? So for chiropractors, that’s common for record Puncture. It’s not, but we’re acupuncture does help.

Some common issues. Common issues for acupuncturists are under something called the Medically unlikely edits.

Medically unlikely deal with codes that can not be coded for an excess amount of units. Now you may think, what does that mean? This is where it comes in. You’ve noticed where they’re saying acupuncture can only be billed for say three sets or two sets depending on who you’re dealing with. That’s what they’re referring to. So what are you Louise there for any CPT code that the maximum amount of services that will be provided under one visit or a date of service, this applies to all types of codes. So by example, to show you where it’s also applies, it’s not just for acupuncture. Things like modalities have one, some have four. If it’s an attempt to Allie, when it’s timed such as notice the here it’s just the unattended services or one notice the codes for electric STEM allow for, but then ultrasound is only two. And again, that’s just based on these edits that say that’s the maximum per visit we’ll procedures. Get a little bit different. Notice for exercise nine, seven one one zero. It is six

For neuromuscular education. It is, it is for

Because it’s a little different service than exercise. So they’re limiting to four notice massage only four. Now you may say who comes up with these it’s part of the coding committees edits that do such. So make sure that you’re using the correct codes and amount of units. Now I doubt many of you go well above that notice manual therapy says six. So these are what they’re going to indicate as the amount that you can do maximum per day. So if you did more than six, they’re going to say no. Well, where does our services fit? You can see here therapeutic activities, by the way, I chose these codes here on the right side specifically because that’s the limits for those codes. But also those are the codes. If you’re billing VA patients, those are the services that the VA will automatically authorize for acupuncture providers.

But here’s what we’re running into. As I mentioned, the VA, take a look here. Here’s what’s called the standard episode of care SEOC and you’ll notice it says for acupuncture 12 visits, but notice it says a maximum of one additional unit of acupuncture with, or without electric STEM when reinsertion of needles. So under this one, and this is an Optum health, when they’re saying, Hey, you can only do two. And I’m sure many of you have run into that. Whereas before you could do four or five, it’s just saying they’re allowing only two. So that’s OptumHealth now again, that goes against what the normal edit says, because notice this one from tri West and you’ll see, this is really just from December. I know you can’t see the date, but you’ll notice here. It says the maximum unit

Acupuncture. And you’ll notice the map

Maximum units for acupuncture indicate nine, seven, eight one zero. The first set is one unit, but then the additional sets notice are two. So notice they’re indicating under this correct coding under the many medically unlikely edits. The limit is three, meaning one initial set and up to two additional sets. Now to give you a little history of that, that hasn’t always been the case. I want you to see here. This comes directly from United healthcare, and this is dated notice 2018 through 19. And it was different. It says the medically unlikely edits indicated that you can do one initial set, but then three additional sets of manual. And then electoral was one and two only. So three total. So at that time it was four, but let’s fast forward to this year. You’ll notice again, this is the health care notice from 2020. And now it’s indicating that according to this edit notice here, it says the policy enforces the code description for acupuncture services, which are to be reported based on 15 minute time increments, personal face-to-face time.

And it’s indicating in accordance here nine, seven, eight one zero is one. By the way, one makes sense. You can only have one initial set, but then notice instead of it being three, it is now two. So that’s also two here. So what is the new rule for medically unlikely edits for acupuncture is three. Now what if you say Sam, I need to do more now. Medically unlikely doesn’t mean an absolute, could you defend doing more and request more? Sure, but now you’d have to show the medical necessity of what did my fourth set do that wasn’t completed within the first three sets? I think there’s some things that can be disputed there, particularly if you’re doing front and backside sets multiple diagnosis, but again, you’d have to kind of come up with what is the fourth set doing that the others aren’t simple answer.

If you build three, you should not have much problem, but we’re seeing issues here. This is a United healthcare, and you’ll notice on this visit, they’re paying the one initial set they’re allowing it, but then notice this one they’ve taken out. It used this code in three, six, two. So what does [inaudible] mean? Well, let’s look at this full EOB notice in three, six, two says the number of days or units exceeds our acceptable maximum. So let’s take a look at what there are allowing notice on this one, visit on 10 27, they’re allowing the initial set, they’re paying the full amount or allowing it, but then on the additional sets they allow the nine seven eight one one four one and nine, seven eight, um, one, one again, but then not allowing the third set or the third or four set, which would be the nine, seven eight one three.

Now, even this one here, what I’m trying to point out is that they’re beginning to say, Hey, we’re not going to pay more than three if you bill such. So you want to make sure that if you’re billing more than three chances are with some payers. And I will tell you anthems Cigna, Aetna, as well as United have begun to really follow this as well as the VA. So what do we need to do to make sure we’re getting paid properly is to make sure we’re number one, sticking within the three. And if we’re going to go more than three, we’re going to have to send explanation, but here’s one of the problems we’ve run into. There are some plans, even like this one that they’re not paying that third. So when that happens, what’s going on. Here’s another one and this is an empire or excuse me, a Cigna, excuse me.

And I’m just going to blow this up so you can see here. It indicates the number of units built for this service exceeds the limit for the day. Now, if you look at this bill though, they’re allowing the first set and the second set, but not allowing the third. So then wait a minute. Why are they not allowing that amount or excuse me, they are allowing that amount. I want to share this one is doing three. So there’s one initial one, follow one follow. But then the fourth is saying no. And that comes from those edits. If you were billing more than three, you’re very likely to be denied for the fourth. Some payers may allow, but most are going to follow these edits. But what if you’re running into an issue with it where you’ve billed only three and they’ve denied it, then I’m going to push back.

Here’s a letter. And you know, you’re welcome to kind of see how it does. It just brings up the points of I’ve recently received a claim for payment that was denied due to the medically unlikely edits. And you’re going to bring up the medically unlikely edits indicate that there should be three. So if they’re only paying for two, this is the response. You have to say, the medically unlikely edits indicate three, unless you have a contract otherwise. And I’ve seen a lot of plans doing this. And I think what’s occurred is a lot of them have misinterpreted the edits and somehow are allowing to, so you want to make a little bit of a pushback. In addition, for those of you who are billing Optum, when you’re billing, Optum, meaning VA, and they’re only allowing two, here’s my concern. How is the Western part of the country try West allowing three and the Eastern part of the country only allowing two yet.

It’s the same, the same benefit. And of course it’s because Optum has misinterpreted it and there should be three. So this is a little bit of the pushback. Is this something I’m very excited about? No, I don’t like to see any limitations, but we have to know what we’re working with now. The good news is three sets is pretty typical that most aren’t going even that high. In fact, I’ve taught seminars now for 20 years. And I would say on average, when I asked the room, how many people are doing four sets, it’s a very minor percentage. But when I ask who’s doing two or three, it’s most so again, if you’re sticking within two or three, this may not make much of an effect, but if you’re doing four, a Canon may want to rethink of what’s going on. Now you can see, this is what I’m here to do is help you understand it, help you fight back with it.

And I’m going to say, give me a chance to help you do that. The American Acupuncture Council is your resource for these courses, but also I’m a resource. Allow me to be part of your office, take your phone out, take your camera and just put it over that code. And what that’s going to do is give you an opportunity to hire me for your office, but we’re going to give you the first 30 days for no charge. Give me a trial. Let me help you with a claim. Let me help you show what’s going on. Realize these rules and codes. We have fight back letters and all types of things that we can do that I can aid you and making sure you’re being properly paid and not having something where your claims are constantly being denied. Think of how many times you’ve had denials for ENM codes or other services that were not correct.

What do you do about it? I’m going to give you the rules and the laws, not opinions to fix it. The American Acupuncture Council is your resource. Allow me to be part of your office. You can join for as little as $25 a month, or you can do it with seminars. So I’m going to say, take a look at the services we offer I’ll guarantee you’ll get help. In addition, take a look on our site when get there. I’ve got videos and things of other things that we have done and looking at our news section for updates, we are here to help and I want to make sure today you understand what do I deal with and how do I deal with medically unlikely edits? What do they mean if I can do three great, but what if they’re cutting me less than three? But what if I do four?

How do I fight back for that? So that’s what we’re here to do is to help you for that. So I’m going to wish you well and say, stay tuned next week. The, um, host will be Jeffrey Grossman, and I’ll see you next time. I hope I become part of your office. Take a look at our site, take a look at the services we offer. We’re here to make your office successful. Don’t guess let’s make sure you’re getting paid. We do much more than just simply tell you a code. We make sure you’re doing it right. Thank you everyone.

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