Tag Archives: Sam Collins

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Acupuncture Malpractice Insurance – Do You Have To Pay Them Back?

 

 

what happens when an insurance company sends you a letter that says, we paid you money, but oops, we shouldn’t have, and we want it back.

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.

Well, Hello there, friends. Welcome in to another show. This is one that I think is going to be important to you and to many, simply because it’s going As you’re aware, I do the network where I help day to day offices with issues, but we do seminars. And one of the big questions I often get, and I’ve gotten a lot this year, in fact, in the last month, is what happens when an insurance company sends you a letter that says, we paid you money, but oops, we shouldn’t have, and we want it back.

Do we have to pay that back? What’s the protocol here? Can they force it? Can they take payment from a future one? Let’s talk about the laws when it relates to that. When an insurance company makes a payment. And then later decides it’s a payment they shouldn’t have made and now is requesting you to pay it back.

Let’s go to the slides. Let’s take a look at what the laws tell us about this. Cause that’s what’s really important is to understand where’s the responsibility. Think of this, you bill an insurance, you verify it and they pay you. And then later they say, oops, we shouldn’t have paid you. The first place we might look is what did the statute of limitations say as far as how they can recoup it?

My goodness, we have a statute of limitations with many insurances that can be as little as 90 days. Often it could be a year and some may be a little longer, but generally a year or less. So if there’s a statute of limitations for them to Make a payment to us, us sending a bill. Is there a statute of limitations for them to force it back?

Let’s take a look at some of the states here. I won’t say I have every state, but this will at least give you an idea. Under federal law, they can do for one year for any reason, just for whatever. And that’s under Fed, so they can force that. But the states are a little bit different.

Look at these first states, Alaska, Hawaii, Idaho, Delaware, they have no statute of limitation. So then what happens in those states? What that will happen is it defaults to the federal statute. I’m going to say it’s going to be. A year. However, look at states like Georgia, 90 days. South Carolina and Texas, 180.

Arizona, California, one year. Notice it only says 12 months. 12 months and one year, a little bit different. I know that seems a little weird, but nonetheless falls in that. What this boils down to, though, is they have a time limit that if they don’t send the request within this time, They can’t force the refund.

So by example, in Georgia, if they send it to you and it’s a year later, you can tell them, go fly a kite because statute of limitation is too old. Much if you send a claim, you’ve all done this. You send a claim a little bit late from the statute, what does the insurance say? Oh, we’re not going to pay.

Kind of like catching an airplane. If you don’t make it by the time it leaves the gate, you’re not getting on. So don’t be afraid to first push back when it comes to just simply statute of limitations. But I want to take it a step further. Because at some point, who’s the responsibility for it? Think of all the work we do to verify insurance.

They say it’s going to be covered. They pay it. And they come back later and say it’s not covered. Let’s take a look at a letter like this. This is under a federal plan. And I think it’s interesting to how this is written. Notice it says here, Dear Billing Department, they’re sending this to us. And it says, in regards to the request for repayment of a claim, the request made to you was voluntary.

Now I want everyone to notice that statement. Now, not often do they say that, but in this case, they’re clearly stating it’s voluntary. So it’s a voluntary overpayment request because you are in Network Provider, you do not have to pay back any overpayment if the overpayment was discovered after 365 days.

Again, this is under the federal plan. So it’s one year. So notice they’re saying, oops, we made this payment and we shouldn’t have, but since it’s over one year, we’re asking nicely, would you go ahead and refund it? My answer? No. Why would I refund it when there’s no requirement? In fact, what they’re saying is We made a mistake.

It’s our mistake, but we want you to pay us back and you chase after your patient to get the money. And I’m gonna say, no, you’re the insurance company. You made a mistake on paying it. You go after your insured. That responsibility is yours, not ours. And again, notice how they put it voluntary because There’s case law that goes with this.

And here’s a letter that goes over the protocols of when an insurance company pays something wrong and they later want to recoup. And now what I want to do here is emphasize really where the case law is. And it goes into this. It says, I would like to bring your attention to these cases. Federated Mutual Insurance Company versus Good Samaritan.

This dates all the way back to 1974, by the way. So none of this is new. Where the court held that an insurance company could not recover the mistaken overpayment. And determine that the insurance company is in the best position to know what policy limits are and must bear the responsibility of their own mistake.

So let’s say, by example, you bill an insurance. They say they have 20 visits for acupuncture. Great. You bill all 20. And then they come back and say, Oops, we made a mistake. It turns out the patient only has 10. They told you it’s 20 and they paid for it. Now they want to come back? No, that’s their mistake.

This is what it’s highlighting. And that goes on here for the City of Hope. Notice this dates back to 1992. It says, Where the court held that in the absence of fraud. A health care provider is not legally obligated to refund payments it receives from an insurer if the insurance subsequently determines the payments were paid in error.

Now again, this is not something you did wrong. You billed it and they just said, oops, there was no coverage. Maybe the person ran out of visits. Maybe the person had limited coverage. Whatever the case may be. Whose responsibility is that? The insurance carrier. So I’m going to suggest do not be afraid to push back and say, based on these two case laws, we shouldn’t refund because it’s your responsibility.

However, what if you’re in network? Here’s where things get tricky. Generally, when you’re in network with a plan, your contract has language in there that says, even if we make a mistake, you have to repay it. That would be true based on the contract, unless The statute of limitations is greater. So notice the federal plan.

Even that one knew after statute of limitations they can’t force it. So the first place to look if you’re in network is to see whether or not it fits the statute of limitations. If it does not, then going to push back on it. But if it does, they’re probably going to force it. You may try sending the letter that I just had here and see what they may respond, but generally they’re going to say no.

In fact, this is what you might find. What if they deduct payment? From a payment? That’s a future payment. Under the contract, they can do that. Now, what if you say, but Sam, they deducted it and it was from another patient? It’s not a HIPAA violation because they’re not sharing information.

They’re just saying, hey, we paid you a hundred dollars before and we shouldn’t have, and we’re going to take the hundred we’re paying you in the future. Again, based on contract. But what if you’re out of network? Do you have to accept that if you’re out of network? If they’ve already deducted the payment.

Obviously, you’re aware of possession is 90 percent of the law. Now it becomes us to push back. I will tell you, I had an office, this is a few years ago now, that an insurance had recouped 6, 000. They pushed back, took to court, they won. They won not only the amount, but some damages, as well as attorney’s fees.

The only problem is it has to be worth it, because what if you’re talking 100? Is it going to be worth you to file what it takes to go against an insurance company? Probably not, but don’t be afraid, and I’m going to suggest always push back, Statute of limitations, number one. Number two, the case law. The insurance company’s in the best position.

Is it our responsibility when we’ve already done everything to make sure that the policy was covered? And what’s the best way to know a verification? Bill and they pay. And if they’ve paid it, And they later come back and say, it’s our mistake. Generally it’s theirs. Do not be afraid to push back on that.

Here’s something to point out. This is an Aetna insurance. And take a look at, this is an important one. It says, our records indicate the overpayment as noted on the enclosed document is not eligible to offset. So you’re either out of network or it’s past statute of limitations. So they’re saying we can’t offset it.

We can’t take it from money. Therefore we must request that you issue a check or money order payable to us for the above amount. So we’re saying will you please be nice? My answer is, no, thank you. Do not be afraid to push back. They’re obviously looking to see if you’re afraid. Many times you get these letters and IDOT offices just flat out ignore it.

Unless they can force it, what are they going to do, take you to court for it? No, they’re just hoping you don’t know the case law. They’re going to take it in the short. So always be available to push back. Don’t be afraid. In fact, get your patient involved. Ultimately, their policy is one that they assumed it was correct when it was paid.

How do they come back later and say no? Don’t be afraid to push back. As always, the American Acupuncture Council Network is there for this type of question and many more. This is what we deal with on a day to day basis. Take a look at our site or come to a seminar. I’d love to see you in the future.

Otherwise, please take care. Wishing you best, my friends.

 

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Acupuncture Malpractice Insurance – Best of Billing and Coding for Acupuncture

 

 

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

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Acupuncture Malpractice Insurance – What Is 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?

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Greetings, 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?

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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.

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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.

 

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Acupuncture Malpractice Insurance – Diversify Your Practice and Increase Your Bottom Line

 

 

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?

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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Greetings, 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.

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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?

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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.

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Acupuncture Malpractice Insurance – Acupuncture Preauthorization

 

 

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.

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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.

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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.

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Acupuncture Malpractice Insurance – Are You Ready to Request A PPO Rate Increase?

 

 

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.

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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.

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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.

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