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Click here to download the transcript.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
I’m having insurance carriers that are coming back and pushing back on some providers or they’re requesting additional information. How do we define 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.
Greetings, everyone. This is Sam Collins, the coding and billing expert for acupuncture and the profession meeting American Acupuncture Council and you. I’m getting a lot of questions as being an expert dealing with lots of issues from writing articles. I get people asking all the time. How do we make sure we have medical necessity?
I’m having insurance carriers that are coming back and pushing back on some providers or they’re requesting additional information. How do we define it? But I want to go beyond just the carrier. What really is acupuncture medical necessity? How is that defined? Let’s go to the slides. Let’s get into that a little bit and start to give you a good understanding of how do you want to start to approach this, or at least begin to define it.
So you can define your care. What is acupuncture medical necessity, and who says? Of course you can have the patient. The patients are going to determine medical necessity. Whether or not they want it or not is going to be part of the necessity. Does it make them feel better? Who also determines it?
You, the provider, the doctor, if you will. You’re defining it. How do I define it? What is it that the person should feel? What should they be better about? Or what are we doing? Are we just getting rid of pain? And then, of course, we have to deal with it from an insurance standpoint. And how do we meld all of these things together to start to bring to what really is a necessity and how we might define it maybe slightly differently depending on who it is.
From a patient standpoint, think of it this way. A patient’s going to say, it makes me feel better. It has value. If you can have a person that had migraines. And they come to you now and their migraines are 75 percent less or not at all. There’s a value. They’re going to pay you for that. That is something that they see a value proposition for.
Do keep in mind though, people do things, and this is something my mom always defined, that’s why I’m quoting her. She says people buy what they want and beg for what they need. Have you ever had someone borrow money from you before? Maybe they’d pay rent or something. And then they haven’t paid you back, but the next time you see them, they’re wearing a brand new pair of shoes and you’re thinking, wait a minute.
How’d they buy a new pair of shoes? Haven’t paid me. Because they begged for what they needed, which was to pay rent, but they bought what they wanted, what were shoes. I want you to think of, for cash patients, You have to be the shoes. The person wants it because there’s enough value. How do we create the value?
Because they feel better. They can see the change. So realize that even applies and of course applies for insurance or excuse me, for cash, but even insurance to an extent. Remember, some insurances pay really well, but what about the ones that don’t? High deductibles. We have to create that the patient can see the value.
For me, for acupuncture, this is where I think our biggest growth can be. As people try acupuncture, They begin to realize how much it works. Realize that in the VA, while not very many people are seeking out VA benefits, but do you know for people who do get VA, 38 percent are going to acupuncturist. What are the responses?
It’s very good. Why wouldn’t a VA patient want it when they can see it makes them feel better? Because at the end of the day, it’s treating someone to get them to go, oh, there’s the value, there’s no longer fear. So bottom line is a patient finds it, did it help me? And how do we define health? Always by, do I feel better?
Does it have any less pain? And that’s going to be either with insurance or cash. But create that so the patient understands what are the expectations of care. And then of course it’s how you define it as the acupuncture provider. What are you defining it as? As chi or energy, the very more of A traditional medicine basis, or are you going to go just into, hey, let’s talk about it from pain or dysfunction.
In fact, if you have a loss of qi, what is it going to mean? Maybe a loss of energy, but pain, dysfunction, functional change. And so setting up what the expectations are, what are your goals? So if someone comes in with a headache, what’s the goal? No headache, lesser headaches, less intense. Less back pain. I had someone that completely didn’t want to go to an acupuncturist a few weeks ago, an athlete, I recommend it.
I don’t know. I’m afraid of needles. I said, you got to try it. Turns out acupuncture has helped her. And she, in fact, she was able to compete this past weekend and win a medal at the world championships. Bottom line is, Once people try it, they know it helps. Here’s the end of the day. How are we defining that?
I think it’s mostly getting to people so that they can see that the care is helpful. At the end of the day, necessity is, I got to feel better. Acupuncture really is genius and simple. How does the body communicate? When something’s wrong, the body almost always communicates with some level of, I don’t care what, he could be cancer, you’re gonna have pain.
So therefore, acupuncture, I think in its genius, has always focused on that communication. But that communication, we can go beyond to say, it’s not just about pain relief, but long term health. Changes to be healthier. Let’s talk about it from an insurance standpoint. What do they see it as? How do they define it?
Insurance says of course, we know obviously it’s pain. It could be acute, chronic, nausea, vomiting, pretty well covered as well. But it has to be medically necessary, must be delivered toward a defined response. something evidence based, like I can show that the patient is better as a result, meaning they want a continuation of treatment that is contingent upon progression towards defined treatment goals and evidenced by specific significant objective functional improvements.
And again, this goes back to outcome assessments. If you’re not using outcome assessments as an acupuncturist, You’ve got to begin. It’s the easiest way to define your changes. It’s the one most accepted because it’s right there. It’s black and white. The patients start off with a 70 percent disability and after three weeks of care they’re down to a 30%.
Yeah, you’ve made them better. Evidence base is going to be your basis. And it says ongoing services, including monitoring of outcomes of progress with a change in treatment plan, withdrawal of treatment if the patient is not improving or regressing. So in other words, simply put, if the person is not improving, it’s not medically necessary.
There’s got to be a change. Now, you could argue without the care, they would get worse. Here’s what it said. Once the functional status has remained stable for a given condition, without expectation of additional functional improvement, any treatment program designed to maintain optimal health in the absence of symptoms or in chronic conditions without exacerbation of symptoms.
In other words, now it’s maintenance. Now, I’m a believer that And health. When you really think of when we say health insurance, is that what we’re really saying? Are we saying sick insurance? And therein lies the difference. And this may be the bridge of getting a patient to understand, are we going to wait for you to get sick?
Are we just going to keep you healthy in the first place? Why eat healthy food? Why go to the gym? Why they have a better lifestyle? All those things are part of health, but we have to start to find where does insurance fit. And it doesn’t always when it comes to healthcare. And there’s going to be a defining difference of getting the patient to understand, which means we’ve got to really understand it from this standpoint.
What are the expectations? Pain. Decrease it. Make them feel better. The body always responds that way. Now, there’s some things that may not be associated. There are some carriers now that even cover PTSD and anxiety. And maybe they’re not painful, but there’s an outcome of change because there’s improvement.
And I don’t care what you have. If you make a person better, they’re going to have better function. Functional improvement, though, best defined by clinically meaningful improvement on validated disease specific outcomes. If you have a headache, use the headache index. You have PTSD, use that index. Low back, use that index.
There’s all types. If you’re a member of our service, we’ve got them all on our side for you. Here’s the bottom line is, show me how the person is better and what they can do in their life or activities of daily living. Of course, any reduction in pain medication. We are the Society of Drugs. How many times do you watch a TV show that they’re advertising a drug?
They don’t even tell you what it’s for, but just say you better look. What about a decrease there? Let’s keep the person healthy. And then objective measures demonstrating the extent of meaningful improvement. So again, always focus on the patient improving because it says here, additional treatment or as an example to reach further durable improvement or ongoing management.
It’s got to be improvement, not stabilization. And of course, anything that you think is causing the patient to have this recur, it’s going to be improved. is going to be an important part because there is a difference between purely supportive care, meaning I’m keeping them even, or flare ups. Flare up comes, we calm it back down.
Bottom line is medical necessity is defined by, am I making a person better? But who is defining it will determine the payment. A patient will define it easy. You’re making me better out of pain? But once I’m stable, the value’s not there. Where do I fit for insurance? The same way. Your goal. Do what you do well for your patients.
Get them better. Define it in ways that people can see it objectively, and in ways that you can repeat. Ultimately, continue doing that job. The more access people get to acupuncture, the more you’re going to see more people, because realize, once a person goes into acupuncture, it’s oh my god, I didn’t think that was going to work.
That’s really our goal. We’re seeing it in the VA and other places. Your bottom line is, Defining necessity by your methods, by improvement, and melding all of those together. They’re not exclusive, but certainly you’re going to have a lot of patients that may not have coverage. Medical necessity is they feel better.
That’s what you do. I wish you well, my friends, and I’ll say the American Acupuncture Council, our network is always there to help you. In fact, we have an upcoming webinar on VA. You can watch it and view it. I want to make sure that you’re doing as best you can to utilize your business, and as your means of a good lifestyle, but the thing you really like doing is helping patients.
Till I see you again.
So I want you thinking along the lines of where are my patients coming from? Where might I seek some additional patients that I’ve never thought of?
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.
Greetings, friends and colleagues. This is Sam Collins, your coding and billing expert for acupuncture and the American Acupuncture Council. We’ve always tried to help you a way to enhance your practice, make your practice better. What is always going to make a practice better is your ability to provide what you do.
But you need patience. So I want you thinking along the lines of where are my patients coming from? Where might I seek some additional patients that I’ve never thought of? Where is that market? You always have to think of you are a business. You are a CEO. Are you doing things to make your practice enhanced?
So let’s talk about where you’re getting your patients. Let’s go to the slides. Where are your patients? Your patients can be a lot of different types. Obviously, we have cash, but in my opinion, there’s three types of cash patients. Cash, prompt pay, prepay can be done. And then for insurance, there’s nine different types of insurance, but what I want to focus in on are veterans.
Acupuncturists are not tapping the market for veterans. Now, sometimes it’s more just they’re not aware, but realize the VA could be a very good add to your practice. And I’ll give you an example. The average VA patient payment to an acupuncturist for the number of visits they get is going to be about 3, 000 for every one of these patients you get.
Imagine you get two a month. How do we do this? Let’s focus in on that and where does this come from? Because realize, acupuncture has been accessible to veterans for quite some time and I think this is where maybe the problem is. Many of you aren’t aware that it’s covered. Imagine how many veterans aren’t aware that there’s this benefit.
So I want you thinking of, when you have a practice, you’re going to do a little bit of both. I want you to have a cash practice, but I would say that doesn’t mean you don’t take some insurance. In other words, cherry pick. If I get an authorization for a VA patient, I have no problem taking them because it’s guaranteed payment.
Now, some insurances I don’t want to take at all because it’s a little risky, but you need to have a bridge. Don’t assume one without the other. Here’s the part I’m bringing up. For veterans, how many are aware that the VA gives you marketing tools? This is available on the VA site, allowing you to use this, whether it be on your website or any other type of business, badging, social media, to make people know that you care for veterans.
I would bet if you put a sign like this in front of your office saying, we care for veterans, I bet you might run into a lot of people coming to your office going, what do you mean you cover veterans? There’s no veteran coverage for it. Because they’re simply not made aware. When’s the time you’ve seen a commercial or any type of marketing for someone that’s a veteran who’s having pain management or other issues that they could seek acupuncture care?
If they’re not doing that, why aren’t we? The offices I’ve seen that have embraced this have really increased the value. to their practice because they’ve increased the value to these patients. VA community care is what we’re talking about. Community care is stuff that the VA can’t do in their own place that they need to do outside or don’t have enough.
Now realize VA does have some acupuncturists that work in some of the facilities, not all. The VA community care program is provides medical care to eligible veterans and their dependents. Now let me be careful. Dependents aren’t going to be covered for acupuncture. So that’s out, but it’s going to cover the veteran for services that are not offered at that facility or aren’t accessible at that facility.
So here’s what we have. Notice here, this is the VA community care network. Notice what it covers. It covers acupuncture, but wait. It covers massage. Now, again, I want to be careful as an acupuncturist, so long as massage is within your scope, the VA will pay you to do it. But in addition, what if you’re a massage therapist?
Think about this for a second. Do you know massage therapists could apply and treat veterans and the VA will cover it? Get this though. You want to see where traditional medicine fits? They literally cover Tai Chi. So wait, can you imagine a Tai Chi instructor who learned about this? They could think, Hey, I could do a class for veterans.
and be paid by the VA? Here’s the problem. This has been around for quite some time, but we don’t have enough people aware. So I think part of it is making people aware that you do it. And I think the access for you is one that’s pretty good. Here’s what the VA says. Acupuncture is often associated with pain management, but it is also useful for other conditions.
In the body of literature for acupuncture effectiveness is growing. Acupuncture may be effective as a stand alone treatment or as an adductor treatment for other medical congestion interventions and notice the evidence map developed by the VA itself. It says this systemic review identified evidence of potentially effective Effect of several pain conditions, including chronic pain and headaches, mental health conditions, such as depression, anxiety, PTSD, as well as indicators such as insomnia.
So they’re really broadening here for the types of things people have. I had one patient. Or one office, I should tell you, that got referred a VA patient to treat weight loss. I kid you not, because they felt it was going to be helpful. It was, and they paid. It wasn’t even for pain management. So imagine this being available.
If you could start making patients aware of it, they have expanded non pharmacological treatments available to veterans by providing acupuncture services. Yet, yet. Yet, acupuncture use remains very low compared to other populations. It’s less than 1%. If you can increase it 10%, you wouldn’t have enough acupuncturists to handle these people.
Who in here, who of you probably could take 10 times your patients? So I’m thinking the VA could be something where we could really get you to access. But here’s the problem. Does the average veteran know that they’re even entitled to this service? They are. We’ve got to make them aware. We need to know they’re aware because what do they cover?
They cover acupuncture. Yes, acupuncture. Up to three sets of needles per visit. It covers the exams, whether new patient exams, subsequent, and so forth. It covers therapies of many types. Hands on therapies, exercise. Massage, Manual Therapy, Tuminog, Gua Sha, and so forth. In addition though, it covers something many of you are going to go, What?
Yes, the VA covers for acupuncture laser. This is actually new for 2024. It always and continues to cover cupping. So if you think of it, the VA is probably the most conducive to allow acupunctures to what you really do. So including cupping. So would this be a patient I want to see? I would. Why? Because they pay pretty decently.
They pay at Medicare rates, but hold on. Don’t get too down sided thinking Medicare rates are better than ASH, by the way. But notice, set one is 40 and subsequent sets about 30 on average. So that means if you’re doing three sets of visit, that’s 100. Your exams are going to be between 120 to maybe 80 or 90, depending on the lower levels for established patients.
But again, within that, supervised modalities, like an infrared heat, pretty cheap, More hands on, or I shouldn’t say hands on, but more modalities that require more expertise up to 25. They pay about 20 for cupping, again, an average. And then therapeutic procedures, hands on, massage, manual therapy, exercise.
Those are going to be between 28 to 40 and those specifically in the mid 30 range. So you can imagine when I talk those numbers, if you’re looking at the number of visits you might get, This is a pretty good patient. You know what they’re looking for? Make them better. Help them. Are you going to cure them?
No. You’re going to help them manage. Help them get better. Help them be allowed to get out in society and be functional. What do they authorize? When you do get these, they do have to be authorized, but they pay for 12 visits within the first 60 days. And what they’re going to look for is, did the patient improve?
If they’ve improved, they will allow up to 8 more visits every 90 days. And they even have one that once you’ve gotten within that, they’ll allow chronic pain management for the patient to use as is, if you will, after they’ve reached PNS or medical MMI, maximum medical improvement. to allow them to treat as they get a little bit of a flare up.
But let’s assume here you’re looking at probably at least 20 visits. And if you’re thinking it’s a hundred plus per visit, that’s where I said 2000 plus exams, a little bit more. So certainly something I’d want to get access to the, here’s the key. If you join and you don’t get a patient, that’s the worst thing that happens.
You don’t get a patient. But if you don’t join, for sure you’re not. What if you join and get a few and make people aware that you help, that you’re helping them? Think of how many patients that are existing veterans or have family members that are. You do have to join. Here’s a map. Notice if you’re Texas or west of Texas, it’s with a company called TriWest.
And if you’re in north of Texas or east, it’s going to be the company OptumHealth. There’s no cost to joining, just have to register. So to me, it’s a no brainer. Worst case scenario, you join, you don’t get a patient. You know who I blame if you don’t get a patient? Us. You. How do people know what you do?
Here’s my problem for acupuncturists. Ask the average person, what does an acupuncturist do? And I think you’ll hear a lot of ignorant answers. And I’m not blaming anyone, but I’m saying we’ve got to do a better job. Because how many people know you can treat anxiety, depression, PTSD, insomnia? Not to mention back pain, neck pain, all those things.
People aren’t aware. They think one thing, make them aware of more. And of course, as you well know, once a person has been to an acupuncturist, very seldom do they come back, Oh, that didn’t work at all. In fact, how many times have you heard them say, I’ve been to so many doctors and I went to the acupuncturist and after one visit, or maybe even just a few, my pain or my problem improved 50%.
That miracle happens all the time, but you got to create access. You’re so anxious to join so many of these other plans that pay you very little. Why not the VA? Understand how the VA works. What do they pay you for? They pay to make the patient feel better, meaning give me a pain decrease. Give me functional improvement.
If I make the pain go away, am I going to have more function? Absolutely. Can I show that they’re probably using less medication, even if it’s over the counter? And bottom line is demonstrate it objectively. If you go through the last time I did this program for you, I did one on authorizations, that kind of focused in on that.
Show me you’re making the patient better. That’s at the end of the day. That’s all that’s really cared about. The VA will look there. I’ve had people say Sam, I’m not getting additional visits when I request it. Did you follow this? I’m the expert that can help you with that. This is just a thumbnail.
We’re doing a seminar. We also offer a service called The Network where we’re going to help you. Don’t feel alone. Know that there’s a lot of sources out there and we’re one of the main ones for you. I wish you well and I want you to be prosperous. Be well, my friend.
One of the things that’s come up recently that I’ve had some issues with is people dealing with pre authorizations. This could be a pre authorization whether it’s a I don’t know, health insurance like ASH, maybe Optum, maybe a VA client.
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.
Greetings, everyone. This is Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council and you. One of the things that’s come up recently that I’ve had some issues with is people dealing with pre authorizations. This could be a pre authorization whether it’s a I don’t know, health insurance like ASH, maybe Optum, maybe a VA client.
And it’s always, what are they looking for? So let’s go to the slides. Let’s talk about that. What is required for a pre authorization? What in the heck are they looking for? How do we make sure to kind of streamline this? Make it easier for ourselves and ultimately know what are they looking for. And I think that’s what’s really important.
So when you’re talking to pre authorization requests, you got to think of who does this come from? Well, number one, I think people think of the plans similar to ASH, American Specialty Health Network. That’s all over. And of course, those require pre authorization, particularly unless you’re a tier six. It could require authorizations after the fifth visit or eighth visit.
So what are they looking for? But we’re also running into issues. Optum Health, who manages United Healthcare is requesting, and we’re seeing it obviously from community care, meaning the va. And this includes Tri West on the West Coast, or Optum on the East Coast, which of course already is there ’cause we know Optum does require that.
But then there’s other plans, I’m sure you’re noticing Aetna, blue Cross, blue Shield, Cigna, and others. are beginning to put this in place. Not everyone, but whenever you run into this issue, one of the difficulties is trying to understand how do I make sure to get the care authorized, make sure I’m not running into a hassle and creating much more work for myself.
So what do they want? Why do they want it? Well, what they want really is a plan of care. What are you expecting to do? What are they expecting outcomes? So you do have to really write up a plan. I want to see this patient two times a week for three weeks or whatever numbers, but it has to be specific. It cannot be open ended.
The ultimate thing that they’re going to realize or look at though, is are you making the patient better? With pre authorization, it often is not the first visit, but it’s follow up visits. Even ASH will allow you about five. So what they’re looking to see is that, well, is this care working? Is it going to make the patient any better?
And they’re looking really, if nothing else, the why? They’re looking to avoid maintenance, supportive, or palliative care. It’s care I believe and I think is useful, but insurance, of course, So they’re always concerned that it’s going to give them just feel good. Now what I find funny about that is how much care that’s medical, meaning medicine, that’s curative?
Or is it maintenance? I mean, if you think of it, if I take blood pressure medication, am I curing it? Or am I just maintaining it low? Well, think of pain management. Well, maybe I’m not curing the reason for pain, but if I can maintain it, isn’t that a good thing? Kind of interesting how that kind of works in that way for us.
However, what I want to focus on is what are they looking for? So when you start doing a pre authorization, there’s some highlights you want to have. Medical necessity, when we look at this from American Specialty Health, and now this is not my opinion. This is taken directly from their guideline. The number one thing they rely on is your diagnosis.
And this is going to be true for anyone. Make sure your diagnosis is one that they cover. One big reason things aren’t covered is you don’t have the proper diagnosis for your care. Notice that they don’t cover everything, but know the things that they do cover and focus in on that. They do pay attention, however, to the past medical history, severity, complexity, Acuity, is it recurrent or chronic?
That does make a difference. When that is in play, it can create a greater need for care. But they also pay attention to comorbid factors. What are things underlying? Maybe I’m not directly treating it. But it’s causing the patient to be more difficult to respond. Maybe they’re diabetic. Maybe they have MS.
Maybe they’re very overweight. Maybe they’re very deconditioned. Anything you can think of that is causing it to take longer is important because otherwise they’re assuming everyone gets well in a few visits. And they do look at your exam findings, whether it’s range of motion, palpatory, orthopedic testing, orologic testing.
And remember for acupuncture, they do pay attention to tongue and pulse. Those are important, but you know what they really want to know? Within all these factors, what are the functional limitations of the patient? What is it causing the patient to have difficulty doing? Because pain always inhibits function.
So I always think along the lines of all these things leading to how are we making the patient better? And better means functionally, not just, I feel better. And think ultimately of what the goals are. So if you kind of start putting this together as a template, this is going to allow you to start to think of what things they’re looking for.
Now this is just American Specialty Health. Let’s take a look. This is the one from Cigna. Now I’m showing in big format here, but notice Cigna says, medically necessary services must be delivered toward defined, reasonable, and evidence based goals. That’s that first bullet. Medical and assessed decisions must be based on patient presentation, diagnosis, severity, and documented clinical findings.
Continuation of treatment is contingent upon progression towards defined treatment goals and evidenced by significant, objective, functional improvement. Do you notice how much they’re bringing in that function? That’s what you want to focus on. So notice it says, examples, outcome assessment scales, range of motion.
So notice, is this very different? From what we saw with ASH, not really. In fact, take a look at the last bullet. It says, medically necessary service, including monitoring of outcomes and progress within change in treatment or withdrawal of treatment if the patient is not improving. So notice the outcome is what they’re looking at.
Show me what they’ve gotten so far, how they’ve changed, what are the expectations, or what are the expectations based upon guidelines? Here’s more of it from Cigna. And you’ll notice again, the emphasis here, measuring progress. Pain scales. That helps. But a pain scale without context is not very good. We want to have interference with daily activities, functional outcome measures, length of relief after treatment.
And you know how a lot of patients feel better for a few hours, a lot better. But by the next day, they feel the same. If you just report how they felt the next day. Your care doesn’t appear to be working, but highlight those factors. But notice tenderness, palpation, range of motion. Here’s what I’m highlighting.
It’s not very different. Maybe semantically there’s some differences, but ultimately the same things they’re looking for. Even the VA jumps in on this. The VA says significant, durable pain intensity decrease. So we want to see pain decrease, but not pain by itself. When pain is better, function is better.
So when a person says they feel better, ask the question, what can you do now that you couldn’t do before? Maybe tying your shoe, driving the car, whatever the case may be. But notice it says meaningful improvement on validated disease specific outcome instruments. Acupuncture works well. Let’s make sure to demonstrate that.
Not just by what we verbally hear from the patient, but validate it. So we want to also highlight any documented elusive, documented lesser use. I don’t care if it’s over the counter or otherwise. If they’re taking less, that’s helpful. And then also look at any objective measurements. Again, things on your objective exam.
And again, you’re going to notice, well gosh, this is the VA, we did Cigna, we did ASH. Does it all kind of come out to be the same? Yeah, in fact, they even say here, include any barriers to recovery such as complicating conditions or comorbidities. But also how the patient has changed to date and how the care will continue the same trajectory.
At the end of the day, show me the patient is getting better. I think the simplest thing to do is always have outcome assessment tools at the ready. Whenever a patient first visits, that should be the first visit, and probably once a week or every two weeks at least, because your care is working. We want to show that it’s gaining.
by having direct measurements. Now you’re going to hear the term data driven care. It’s the data of what you collect. Tracking restrictions on activities of daily living is probably the best way. So you’re going to use what are called patient reported outcome measurement instruments. And there’s lots out there.
General pain index, specific functional scale, the short form for pain interference. There’s a long form. And then pain rating scales. Those are good. Oswestry, but everything has to fit within a goal. Now, some of you who are members in our network, remember our AccuCode has these on there all for you to use and how to use them, but ultimately let’s take a look at how they set up.
Here’s the general pain index. To me, one of the simplest, but most effective. Notice this is not a pain scale. It’s not about how much the person’s in pain, but how the pain affects their family and home responsibilities. They’re recreation, social activities, employment. In other words, if it’s a 0, they’re doing fine.
But a 10 means they’re a mess, and all we’re looking at is a number. The higher the number, the more dysfunction. As the patient improves, the number should reduce. Now you’ll see at the bottom it says the threshold score is going to be 5, meaning that if a person’s score is 55, they’re not better until at least they’re 50 or lower.
It’s got to be a 5 point difference. What you should notice initially, It’s a high number that will drop a lot, at least at the beginning, and then it begins to trickle. Now, that doesn’t mean because the trickle is happening you’re going to stop, but it just shows you’re continuing. An easy way of demonstrating it, because if you rely on the patient saying they’re feeling better, that’s not really going to give us enough evidence, because feeling better in what way?
You ever had a person tell you it’s a 10 but they’re almost functional and another person’s 5 is dysfunctional? So that’s why the pain scale is not as accurate. It’s the pain scale with function. So General Pain Index. In fact, the VA has one they prefer now. It’s called the Pain Interference Short Form.
In fact, you know what this is? It’s the short form for the General Pain Index. Notice, it’s the same six questions, but it just has a five answer. This is what I would say you probably do once a week, maybe the other one every two weeks. All this is doing, though, is giving evidence of how your care is working.
When you are seeking an authorization of care, the best way to authorize more care is to demonstrate how much the patient has changed. And then what the continuation is going to continue, the projection, if we’re improving 10 points or so each time we do this, there’s no reason to discontinue until it begins to flatline and there’s no further improvement.
Bottom line is they’re looking, are you making the patient better? That’s what they care about. Not about how they state it, but notice every single one focused on function. If someone says they want function, Give them function. Use an outcome assessment. Make it part of your daily note. In fact, there’s some new rules that are going to help us with pre authorization.
Now, these rules technically don’t take effect until 2026, but this is the movement. This new federal rule requires that they streamline and disclose more information. Do you ever notice sometimes, They don’t give enough information, I’m providing a lot of it here, but we want to see a process where if you’re participating in any federal plan, this doesn’t include VA and others, they must now respond to an expedited process within 72 hours.
But never greater than seven days. Now, many of them say, Oh, yes, we respond within, you know, five days. We know how that works. I mean, think of some of these VA claims you’ve probably requested. They can take a month. Now, they’re requiring that they respond sooner. ASH can respond pretty quickly, but it’s almost always negative.
So, if that’s the case, they must also include their reasons for denying. Often, when I deal with an office on getting pre authorization when they’ve been denied, The best way that can help them is I take a look at what was denied and the why to make sure when we make the next request, we hit the points that they want.
Remember, when someone wants A, B, and C, give them A, B, and C. I don’t care what you think, get what they want. Now that doesn’t mean if you like doing A, B, C, D, E, and F, great, but their focus is A, B, C. Give them that as the primary. Realize now you’re going to have a little bit more of a framework to look at.
Most often when they do give a denial, they’ll give a little bit of this. Now under federal rule, it’s going to be required. Don’t be afraid of it. Your care works. Demonstrate it. As always, the American Acupuncture Council Network is here to help. If you need some one on one help, want to make me part of your staff, join our network.
I hope to see you. Otherwise, everyone, I wish you well.
So is there a way? To request or to get an increase in a PPO rate, because if you think of it, they never do it, but is there an opportunity to do yeah…
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.
Greetings, my friends. This is Sam Collins, the coding and billing expert for acupuncture and for you, but the profession as a whole. Thank you, American Acupuncture Council, for the opportunity. But let’s get into it. What’s going on, particularly for the first of the year? You’re always thinking business, money, pricing, and many of you have joined these HMO slash PPO plans and may have been in them for years and are noticing them.
I’m getting paid the same thing, year after year, and at some point that becomes unsustainable. So is there a way? To request or to get an increase in a PPO rate, because if you think of it, they never do it, but is there an opportunity to do yeah, I will certainly say I’ve had offices that have had success in getting rate increases for PPOs, but there’s a way to do it that I think will lend to potentially having more success.
This is no guarantee, but potentially more success in getting a rate increase. So let’s go to the slides. Let’s talk about that. What things do we need to do? To help ourselves request a rate increase and really get one, it comes down to making sure you create really a value opportunity about your office.
I want you to write a letter to them and request specifically an increase, but by writing a unique value proposition that makes your practice stand out. Maybe where you’re located. Okay, it might be an underserved area. Those types of things are helpful, but more than anything, always go by what’s your status within the plan.
Show your value. I’m sure many of you have heard of the company ASH or one similar, and you can rise in status from Tier 1 to Tier 6. Obviously, the higher tier status you have, The more prestige you have in the plan, and that creates more of a value. They want to keep those higher performing providers, and if you are one of those, that certainly makes it much, much better.
You want to also focus in on your utilization. Bear in mind, we do understand these plans raise your tier by not over utilizing care. That doesn’t mean you shouldn’t do the care that’s necessary, but be mindful, they’re not expecting everyone should get 20, 30 visits. They’re expecting, actually, an average of about 8 visits per patient.
And what that means is, you’re going to have some patients that you might see 20 times. They need it. There should be a balance with maybe seeing some of them two times, so that average comes in. Realize, don’t let one patient plan set it up, but the average over time. And if your numbers are lower, you can show that.
You would point out, heck, my average is six, let’s just say. You want to also highlight, what about the number of providers that might be in the region? Some areas are very underserved. Particularly now with the viability of acupuncture, the VA and all these things, they’re looking for providers. And if it’s an underserved area, that’s going to help.
But even if it’s over served, if you will, there’s a lot of providers. Where do you stand out? Your availability, your location, your hours. Your languages you speak. What if you have multiple languages? I would highly recommend if you have multiple languages spoken in the office, it should be brought up.
Do you speak Spanish? Do you speak Tagalog? I mean think of any type of language. It’s gonna be helpful to create access because that’s very important these PPO plans always creating access. Make sure you also point out their value Compared to other existing contracts. Other plans you’re part of, but I would start with Medicare and Workers Comp.
My goodness, even Medicare for two sets? When you look at the Medicare rate, it allows 70. Workers compensation is usually a percentage of that. Usually anywhere from 120 to as much as 200 percent of Medicare. So therefore, you want to start to use that to say, how is it a PPO thinks they’re sustaining when they don’t even meet the value of Medicare?
And Medicare is the low end. ASH is going to pay many acupuncturists 40 to a visit, which is literally one set, even for Medicare. And if there’s two sets for Medicare, you get 70. So it’s probably unsustainable, and it’s not reasonable, really. Because you have to look at inflation and cost of practice.
Don’t be afraid to bring up about your own specific issues in your practice. What does cost more? Certainly, when you first started practicing, your rates have increased. I’m looking at rates of rent now, which are through the roof. Could that be sustained? Look at gas, the cost of phone and internet, all those things are part of a practice and cost.
So you have to make sure that you’re creating all of that with the window to show your value and unique value to that plan of how you’ve helped people. Don’t be afraid to get a few testimonials from patients of how you’ve helped them. Make sure there are ones too that the patients didn’t have something where they needed hundreds of visits to.
But nonetheless, those types of things are going to be helpful because an insurance company has a vested interest. and making their clients Happy. You want to show that’s what your job is and what you have done. So here’s a way to focus that. This would be the highlights of how to put together some type of proposition or letter to the carrier.
And you can point out, I’ve been a panel provider since say 2015. For some of you, it might even be longer. I support the development of managed care in acupuncture because it helps to standardize documentation, promote evidence based care, and create greater accessibility. We want people to have access to get acupuncture.
We do. But we’ve got to make sure in doing so, we have to have a reasonable amount that’s paid to us to sustain it. You’ll highlight to them there’s been no significant change in reimbursement from your plan, and I’ve been a member for decades maybe. These days, I’ve increased costs. Staff salaries, rent.
Think of the work we have to do now with electronic health records, electronic billing. All the costs that are there. A lot of these plans require you to bill electronically. That doesn’t happen for free. Therefore, that’s got to be brought in. Software contracts and so forth. Not to mention your rent and the other things that go with maintaining your practice.
And frankly, the cost of other things. Cost of gowns. Cost of needles. It’s all increased. You’ll highlight to them, my overhead is nearly four times of what it was when I enrolled with you. My average cost of seeing the patient now is 41 a visit before there’s even a profit. So some of these plans are paying as little as 40.
So you got to think, wait a minute, if my cost is 41 and I’m getting 40, does this make any sense? No. Can you imagine every business just exactly makes what their actual costs are? You can’t stay open. There’s just no way. So this level of reimbursement is not a sustainable model, and while being on the plan to create a greater volume of patients, there’s still a limitation.
Let’s face it, an acupuncture visit is typically 30 to 45 minutes. How in the world can you sustain a practice where you’re getting paid? Less than 80 for an entire hour of work, maybe an hour and a half, and then going to be able to maintain that practice to be open. Think of just what you’re paying per square foot.
In some ways, I would argue we might be better off working at Starbucks or Panda Express, considering some of those places pay 40, 000 to 80, 000 a year. For a full time worker. Come on, as a healthcare professional, they can’t have rates that are at least sustained at that level. So you want to start to point out that hypocrisy by pointing out the rates for your insurance have increased to allow the plan to remain solvent.
I get that. Has insurance companies increased the rates to their insurance every year? I know and I redo my insurance every September. There’s been an increase every year I’ve been in there. However, are providers part of this increase? Isn’t it interesting how insurance companies typically say we’ve had to increase the rates because of the increase in cost.
And I agree, there’s an increase in cost. Where isn’t there an increase in cost? What provider is still getting the same, paid the same amount they have for years? So in reality, the provider costs are flat. Yet, they get all these raises to do what? Now maybe that’s to cover drug costs and all that, but at the end of the day How could they say we’re part of an increased rate when they’ve not paid us any more money?
They’re thinking you just can see more people. How could we see more people if it takes that much time? So it’s unreasonable for providers to bear this cost with no consideration, while the plan has increased their premiums and the adjustments in pay to their workers. If you work for these plans, I bet many of them, if not everyone, get some type of adjustment yearly, 2 to 3 percent.
I’m looking at least for that. I would think if you haven’t had one in a while, what about a 10 or 20 percent jump for this year? Because to sustain it in this way at some point just cannot be sustained. In my observation, healthcare services are the cornerstone of this business and have been left out.
I’m requesting if you’re getting per diem or even if it’s per service, a certain request over that, which will allow me to continue to welcome these patients to my office in the future. Because without an increase, I will no longer be able to sustain the relationship. Let’s be reasonable. It just won’t.
In fact, I’ve had a lot of offices that realized that it was a sum negative and they’ve dropped out. And this is someone I spoke to last week. This is not an exaggeration. They pointed out that they dropped out of one of these plans and they first were very panicked because they thought, Oh my God. And they go, Oh my God, Sam.
In the first two months, they lost 30 percent of the patients. But here’s what they realized. They lost 30 percent of the patients, but that only equals 6 percent of the revenue. What does that tell you about this plan? How bad it is? All this work and emphasis. Maybe it’s not worth it. And this is something that you have to start to look at as a business decision.
There’s nothing wrong with being part of these plans if they’re at a sustainable rate. But if they’re not, maybe it is time to move on. And this is what we look at. If they can’t sustain it, then let’s move elsewhere. Don’t be afraid to make a move. Don’t be afraid to request. Because at the end of the day, the power is with the providers if we wield it.
And don’t be afraid that ultimate power is your patient. And if that patient is still coming in without the plan and paying a fair rate, why would I push for this thing where I’m getting paid 25, 30? So do be careful, but I’m not saying not to request, not to do it, but at least this way you’ll know where you stand.
And if they’re treating you that poorly, maybe it’s time to move on. Don’t be afraid to break a relationship that relationship does not have mutual parts that are beneficial to both sides. And that rate increase to us, I think is important and without it, maybe we can’t stay there. So don’t be afraid.
I wish you well, as always, the American Acupuncturist and myself are always there to help our service. The network is a place where you can go and work with me one on one to really write up a protocol like this. I really wish you all well, continue a good practice and enjoy what you do.
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. It’s Sam Collins, the coding and billing expert for acupuncture and the American Acupuncture Council. We’re here for you and we wanna make sure your practice continues to thrive. Let’s get into it. Let’s talk about what’s happening with documentation of acupuncture services, specifically time services.
This is continuously a problem and I want to help you solve that and make sure you understand it with some ease to make sure your claims are paid. Make sure you’re getting paid what you’re supposed to be paid. So let’s go to the slides, everyone. Let’s talk about documenting and recording time specifically for acupuncture.
Where we’ve run into a ton of trouble is to realize that acupuncturists probably never really learn this correctly and don’t understand the value of their time. I think acupuncturists probably more than any other provider, spend more time. With their patients one on one and any their provider, and I’ve been to lots of different types, but my acupuncturist is the one I spend the most time with.
All I’m saying to you is that’s true. Let’s make sure to document it. So acupuncture highlights specifically time and I underline it here. Notice each of the codes indicate initial 15 minutes of personal one-on-one. Contact the additional one each additional 15 minutes with personal. One-on-one contact.
So it means acupuncture requires that you spend time one-on-one with the patient, and of course, inserting needles. Now I just highlighted the manual acupuncture, but it’s the same is true for electro acupuncture. Whether or not it’s electro or manual, please document the time. It’s the one area that so frustrates me ’cause I have so many good acupuncturists who are doing really well in getting paid hundreds of dollars per visit On some insurances, I kid you not, but we run into problems where their claims are denied and I want to see what’s occurring.
Here’s one for United Healthcare, and you’ll see here this is for 9 7 8 1 1 N one three and it says, not supported. It says the add-on type of code requires a primary code. It cannot be accurately seen. Therefore the validity of the accuracy of the bill services cannot be verified. So in other words, there’s no time you think no, it doesn’t say that.
Let’s see. 9 7, 8 1 3. The initial one says the submitted medical records do not support. 9 7 8 1 3 was performed. The documentation submitted does not indicate the time. Was personal one-on-one contact. Now notice it’s telling you the time didn’t indicate as personal one-on-one. It is not sufficient to just say time, because time could be the time the patient is resting on needles.
We wanna know the one-on-one time. Now here’s an interesting one. Notice some of the claims and initially for the followup set says not supported. Notice the initial set is, so what did they do differently on the first? They didn’t do on the second. You’ve got to get in the habit of saying, I spent one on one time.
So by example, what is this one-on-one time, and I think many acupuncturists forget what this really includes. So let’s get into this 15 minute code. The 15 minute code is personal. one-on-One contact. Literally that means on an acupuncture visit day, not with exam, just treatment. As soon as you walk in the room with a patient.
The time starts. So what I’d like you to do is look at your watch and go, oh, start at 10 0 5, or whatever the case may be. Give me specifically the start time, or at least start a timer because this means, and you’ll see here, the acupuncturist is in the room with the patient and actively performing a medically necessary act component of acupuncture.
Now, realize, what is that gonna include? When you first walk in the room, you might review their note and say, Hey, last time you said such and such. That’s included. It’s going to be review of the history, asking them how they’re feeling. Notice none of this is even yet putting needles anywhere, but just asking the patient what’s going on.
It’s then going to include your day-to-Day evaluation could be tongue and pulse, range of motion. You name it. Any of those things you might do realize includes washing your hands, sanitizing. Choosing the points, cleaning the points, getting the needles open, inserting the needles, manipulating the needles if you have to.
And of course it actually includes removal so you know how you’re in the room with a patient. You might leave them rest on needles. I. Maybe you come back 10 minutes later, as soon as you walk in the room, time starts again because the time to take the needles out and dispose actually counts and notice this component as well as completion of chart notes while the patient is present.
So that means, you finish it up when the patient’s there, that actually counts. Now what wouldn’t count is if you do it later sitting in your office, but if it’s while the patient is there, it all counts. So you know you’re asking those few questions at the end. Just gimme the total time. I love that we’d have a program somehow.
Maybe there’s a mat. When you walk in the room, the mat turns on a timer, and when you walk out of the room, the night timer goes off. Because if you’re in the room, it’s a component of acupuncture. You’re doing something towards it. Unless it’s another therapy. Now, where a lot of people get fooled on this though, because they said Sam it’s 15 minutes.
Do I actually have to spend 15 minutes? Technically, no. It’s what we call the eight minute rule, and this eight minute rule is true. For all codes that are 15 minutes when it comes to CPT, including physical therapy and physical medicine, but actually acupuncture. So I’ve given you a simple breakdown of it.
Notice one unit is at least eight minutes. So do you have to spend 15 minutes to do acupuncture? No. If I spend eight minutes and insert a needle. I can remove it and they’re out of there. That actually could be enough time. Now, I don’t think anyone’s doing an eight minute visit, but I think you get the premise here is that we’re just looking in increments that if you’re doing more than 50% of the time, meaning eight minutes, you qualify.
I don’t think anyone has any problem doing the first eight minutes. Of course, where things get a little trickier though is how do we do an additional set? That requires additional time and additional insertions, but it doesn’t require. 15 minutes. The answer is no. It requires an additional eight.
Now here’s where it’s confusing though. What if I do eight minutes on the first and go, I did eight minutes on the second. What’s the total time for eight plus eight 16? Is that enough? No. ’cause there has to be at least 23. So realize the second unit of time, that eight minutes begins after 15 minutes and it’s plus eight.
So that’s why you’ll see one unit is as little as eight, but two units or two sets is 23. Three sets would be 38. So you have to make sure that time matches. So by example, if you did eight minutes on one and eight minutes on the other, that wouldn’t be enough. It would’ve to be 15 plus eight. Or how about this?
What if you sp you spent 12 minutes on the first one and 11 minutes on the second one, would that be adequate? It would, because there’s 23 minutes, so please make sure that you’re just simply documenting the time. Notice it wasn’t saying, the time wasn’t documented, they were indicating the time wasn’t clearly indicated as face-to-face.
So get in the habit of saying face-to-face time with the patient. Because what if there’s time where the patient’s resting on needles? I know when I go to my acupuncturist, she will put in needles. Then she usually leaves the room about 10 minutes or so. Great. It gives me time to relax. Realize though that time simply doesn’t count towards the coating, but then when she comes back, it does.
So it has to be actively part of it. So if you come back in the room and stimulate needles, it would be if you come back in and insert more, that would be an additional set. So please note here it says yes. Do you have to do insertion of needles? Yeah, reinsertion. Bad term of course, but additional insertion.
So keep in mind, just retaining needles for an extended period of time does not give two sets. Stimulating needles does not. There must be an insertion. So keep that in mind and realize I’m showing. This is from Regents Blue Cross Blue Shield from their acupuncture part. Notice it says here, eight minute rule, eight to 22, 20 23 to 37, so you can see clearly.
This is not just a SAM rule. I’m not trying to just say I’m the know it all. No, I’m giving you the rule based on the guidelines. Notice it says if you do seven minutes or less, doesn’t count. As soon as you do. Eight minutes. Yep. So right in there you can do it. So realize that UnitedHealthcare is the one I just showed you that had a problem, and it says, for any time-based code, the duration of service must be clearly documented.
And the time service is not clearly and properly documented, then the service is not supported. And it needs to be because we have to indicate face-to-face time, acupuncture. Often patient patients will rest on needles. And so the reason that we’re seeing some of this is ’cause I think we’re combining that and not separating it out or.
Just not making it clear. Just make it clear. Notice a couple of things here because it tells you how you document, so you might wonder, how do I’m supposed to document this, Sam? It’s unacceptable Documentation of time-based services. What’s unacceptable? Documenting in terms of units. You can’t just say, I did two sets of acupuncture.
You can say that, but I need you to tell me set number one, how many minutes did you spend face to face and where’d you put needles? We cannot use a range of time. You can’t say, I spent between 20 and 25. It should be, I spent 20 or 21 or 22. You also wanna make sure that you’re not specifying a measurement or increment used, meaning that I did from this time to this time.
That range part, or just not mentioning time at all. I think the easiest way to see this though, and for those of you that have been to a seminar with me and or have our accu code, you’ve seen this is a sample of a soap note. What I wanna do is just blow up. Where the area is, that time is documented.
Take a look here where it talks about acupuncture and it says Set one, two, and three. Now realize this form. If you wanted to add a force set, you just add another column, but nonetheless, notice set one. The points that were inserted or reinserted could be either one. We list the points and then we indicate face to face time five 20 to 5 45.
That’s 25 minutes notice, there’s retention time. There is a rest period, but notice set number one is 25. Notice set number 2, 5 55 to 6 0 5. That’s only 10 minutes, but does that meet the eight minute rule? Yeah, it’s more than eight plus. The first one being 25, that’s 33. We’re easily above. And then notice the third set is six 10 to six 30.
Now, may wonder how come the middle set was so much shorter? Doesn’t take that much time to add more probably. And the last set was also 20 minutes. Why was that last set longer? Think of all the things you do at the end of the visit, counseling the patient, removing the needles, and disposing. Just give me the time.
None of that is hard. Acupuncturist by, right? Always brag about how much time they spend with someone. I talked to someone this morning that goes, Sam, I spend God between 40 and 50 minutes with every patient, and I believe that to be pretty true. For most of you. You know what I want from you. Document it.
You’ll never have an issue. Now you may think I only do cash. Great. You still have to document the services. So realize this has nothing to do with insurance. This is just to do with you properly documenting what services were provided. Tell me how much time you spent, what points you did. We’re good.
It will also equal you get paid. I’m not sure you’d notice, and I’m not gonna go back to it. Did you see the prices on some of that United Healthcare? So if you wanna rewatch this later, you’re gonna go, oh my gosh. Now, I’m not saying we wanna bill that much, but if you’re in certain areas, why wouldn’t you bill what it’s actually worth?
Acupuncture is a great service. You’re at a great time to be an acupuncturist. Take advantage of the advancements of your field in getting access. Please document the time. It’ll never be an issue. I wanna say thanks, but realize we’re always here to help our network service and our seminars are where you can go for one-on-one help.
We can do zooms together and deal with you specifically, not just a general question. Please go out and do well because we’re dependent on you, the American Acupuncture Council and myself. We count on you. Your success is ours. Until next time, my friends.