Tag Archives: Sam Collins

What Language Are These Insurance Companies Speaking?

so I want to go through some of the terms, what they mean to make sure there’s a clear understanding, because I’m finding often there’s a lot of misunderstanding, and because of that, there’s It creates some problems on collections.

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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.

Hey, greetings, my friends. It’s Sam Collins, your coding and billing expert for AcupunctureU, and of course, the American Acupuncture Council, giving you another episode here. And what I want to talk about today is a lot of questions I’ve been getting recently about what are the different meanings of terms and understanding.

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I think this is often affecting our reimbursements. And so I want to go through some of the terms, what they mean to make sure there’s a clear understanding, because I’m finding often there’s a lot of misunderstanding, and because of that, there’s It creates some problems on collections. So let’s go to the slides.

Let’s talk about understanding insurance and the billing language that’s associated with it in the terms. Cause like with everything, the better you can express or understand, the better we like to get paid is I think it’s going to create problems with reimbursements. Let’s talk about first, what the heck is health insurance?

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You know, it’s a contract between. The patient and an insurance company often remember that contract is not between us, meaning the doctor and the patient, but the insurance and the patient. So ultimately with insurance, that’s their contract. If it doesn’t pay, that means the patient owes unless you’re in network.

So understand health insurance is a contract not between the doctor and the insurance company, but the patient and the insurance company. Now we may be part of that if you’re a network to some extent, but ultimately it’s their contract. What I want to hit on though, is it really? Health insurance. I mean, there’s preventative things, screenings, but is it really health insurance, or is it sick insurance?

And I think from an acupuncture standpoint, it’s often important to think of it as a There’s got to be something wrong. There’s got to be something where they’re sick, they’re in pain or the dysfunction, otherwise it’s not going to pay. Now, what type of insurance are we talking about? What are we going to see patients with?

Well, we all know HMOs, Health Maintenance Organization. This is a type of a plan that essentially the patient has to go to an in network provider. Now the benefit here is it’s generally going to be cheaper, but they’re limited to go to just those providers. You must stay in network. If you go out of network, not covering, you’re Maybe in an emergency.

Now, the reason this is chosen by many people, it’s just frankly lower premiums and copays because the insurance company gets to control the doctors where they go. So these are the lowest. This is also the lowest in reimbursement for Accu. Now, You may think, can an acupuncturist really join an HMO? Not directly, frankly, but often you join tangentially through joining groups like American Specialty Health.

That often gives access to things like, uh, HealthNet or Kaiser and so forth. So again, these will get access, but they pay very little, so we’ve got to be careful if you’re in these. Is the reimbursement going to be very high? No. This is going to be a volume thing, not really one that’s a fee for service.

Now, what about a so called PPO Preferred provider. Well, this plan allows access to patients to go to in network providers, but it says preferred. So if you go to the preferred doctor, that’s good. It’s cheaper, but you can also go outside so you can access other doctors. But when they do, Or the patient does it, I should say, they’re going to have more out of pocket.

So by example, if you’re not in network with the plan, can the patient still choose to come to you? Oh, absolutely. But the plan may pay less, may have a higher deductible and so forth. So they’re going to realize lesser out of pocket. If they go in network, out of network, maybe more, but maybe the values there.

So this is why many of us will join a PPO with the idea of getting more patients. And, but do remember when you’re part of it. That means you’re accepting a lesser amount. You may not balance bill your full rate. So patients still have a choice of providers, but it’s going to be cheaper if they go in network, hence why many times we join.

Now, of course, it’s greater choice in the HMO, but a little bit greater cost in premiums. I won’t say often a lot more, but certainly more. Now, here’s one that’s unusual, or I shouldn’t say unusual, but is often misunderstood. An exclusive provider organization. Now, you’re going to think, what is that, exclusive?

It’s really an HMO, but it’s a very small HMO. It’s going to be a group of doctors. Or clinics that all group together, sometimes an independent physician association or IPA, and they don’t offer any network benefits. Now these often can be less expensive, but it really limits where the patient can go generally the only way they’re going to get acupuncture.

On this plan is if they have a direct referral because actually the insurance doesn’t cover it. It has to be paid by the group. So they’re often not pushing out a lot of people. This is not a very common policy, but they’re out there for some companies. We’ll do these because they figure it’s going to give greater access and cheaper for them and more access to their patients.

If there’s enough providers. Now, the one plan I think we all prefer, it’s the most expensive, is a traditional fee for service plan. This is your traditional insurance. It’s not a PPO or an HMO, but one that just simply has a simple deductible, and pays for you. 80 20 or whatever the case may be. This is the most expensive plan.

Patients will have lower deductibles and coinsurance. I, by example, have one of these plans. My company is very good to me. They give me a good rate here. I have no deductible and I have no out of pocket. You’re like, how does that happen? It’s very expensive. These have the highest. In fact, they have a platinum.

Here’s what I’m pointing out. If someone comes to you with a platinum program, even if you’re not thinking you want to take Insurance. This is probably one you do, because these offer the most generous benefits, less out of pocket, so forth, because it’ll simply just pay more. Bigger companies often offer these because they can buy it because they’re buying a little bit bigger in bulk.

These are fantastic. Now, if it’s a platinum, it’s great, but if it’s a bronze policy, uh oh, maybe not as good. So keep in mind, fee for service is not as common because it’s more expensive, but obviously the one preferred from a provider standpoint, because it just pays better. But here’s the terms I want to get into.

When you hear a loud amount, the plan pays 80%. Don’t be fooled because it’s 80 percent of what? This is where you have to be careful. Allowed doesn’t mean what you billed. It means what they allowed. So they’re going to have a maximum that will be paid. So let’s say you bill 100, but the plan only allows 50.

That means they’re going to pay 80 percent of 50. Which means they’re going to pay 40. Now, because you billed a hundred, what will you be looking from the patient? 60. Cause you remember you’re not in their network. So be careful with the allotment because patients will say, Oh, it pays 80%. Yeah, 80 percent of what?

Now, if you’re billing within their range, maybe, but many times you might have a fee that’s much higher. And let’s keep in mind, can you just write off a billed amount when you’re out of network? Technically, no. You’re to collect it. So be careful. Now, what about health savings accounts? These are pretty good.

They’re not as popular as I think they should be. But what these are, a patient can set aside money, pre tax dollars, for medical expenses. And they can use it for qualified medical expenses. These I like. This is something that if your patients have these, this is something to let people know, do you accept HSAs?

I would say you do because when they come in, the patient will pay you. You give them a receipt, they submit it and assuming that they have some type of benefit towards it. They’ll cover it. I’ve seen them cover things that often aren’t covered any place else, such as just simple massage for nothing else.

It’s tax free when they use it, so for a lot of people it’s something that’s a good thing, but it’s one that they have to have enough money to do that. You’ll often see this where people have high deductible policies. It makes sense to do that. There is something else, though, that people will see that’s called an FSA.

And they think, oh, okay, FSA is one through the employer. They call it flexible. I’ll say forced. In other words, the company does it, but you can only use it towards out of pocket expenses. So it only pays for like the deductibles and the co pays. It doesn’t allow them just to choose care. HSA is great. They can come in directly to you.

Now here’s something else that is often misunderstood. What about deductibles? Well, deductible, of course, I’m sure you understand the traditional deductible. It’s 1, 000. In other words, the patient has to pay 1, 000 before. Insurance begins to cover. In other words, they’re going to look at the covered costs and once it adds up to 1, 000, then of course, the insurance begins payment.

Keep in mind, the patient doesn’t have to pay it all at once. They could be paying over time, but they have to meet that amount. Now, here’s the parts where it’s confusing. Some services may not be included. There are going to be times you’re going to bill and you’re going to, your bill may be 500, but maybe the insurance only allows 200.

So even though you’ve billed 500, 200 applies towards deductible, but there’s 300 that’s not covered. How much does the patient owe you? 500. So when you start billing, be careful of what you’re billing. The intention is you’re collecting it. So you can’t just bill a high amount saying, well, we’ll see what’s going to happen.

This is why you want to be careful. Do not set your fees off of your highest based insurance. Okay. But not necessarily your lowest, because you want to be somewhere in the middle, but deductibles can fool you. So keep in mind if you’re billing a thousand, 500 is considered, you know, the covered services.

Great. Will the patient owe you 500? They will, because that’s deductible. But what about the other 500? That other 500 they still owe you because you billed it. This is why often people will choose in network. Because if they go in network, then because you’re limited to the fee, maybe that’s where the 500 comes in.

Now there is something else that you’ll see with these, where you’ll see there’s an individual deductible. That’s what we’re talking about here, just a simple one. But you’ll often see a family deductible. So let’s say there’s a family of four. Each person may have a 1, 000 deductible, but maybe the family deductible is 2, 500.

So if other people in the family have met 2, 500 towards the deductible, That means it covers everyone in the family. So someone coming in who hasn’t been to the doctor, that will be covered. So particularly when you’re seeing a family, that family deductible could be a real important thing to know that the patient has greater access just because they haven’t gone to someone else has.

So that’s an added benefit that you’ll find or see there. Now, what does that actually, when you see the term co payment, This is often confused. What is a copayment? A copayment is a fixed amount for a covered service, generally for an in network provider. When you’re in network, you get exactly that. Like some of you are familiar, when you see an ASH patient or that type, it will say we’re paying 50.

And the patient’s co pay is 10. Well, what that means is the plan is going to pay 40 and you get to collect 10. That’s the co payment. It’s always fixed. It’s a set amount and it’s part of the contract we have with an insurance. So think of a co payment is more of a payment when you are in network.

Because it’s a fixed set amount. Now, it’s confusing, because what about co insurance? It’s like, well, how is that any different, Sam? Well, the difference here, I’d like to make the designation, co insurance means you’re not in network. And it’s the money difference that’s not paid, because there is no co pay, because they can’t demand what you charge.

So, let’s take an example. You bill 500. The patient has a plan that pays 200, okay? Okay. They pay 200. How much does a patient owe you? Well, the insurance didn’t pay for 300 of it, so the coinsurance is that difference. That 300. So this is where you can see why a lot of people choose a network because they can just control how much they know they’re going to pay.

Because of course that co insurance is everything that you built. So again, I’m going to state to you, be conscientious that if you’re not collecting the differences and you’re out of network, You probably should just lower your fees because you’re not collecting it anyway. And why set yourself up for a sense of fraud, meaning you’re billing an amount you have no intention of collecting.

So keep in mind, the difference is, is the coinsurance. In other words, what’s not paid by insurance out of network, and you get to balance bill for the full amount. Now that means of course, you’re no longer limited to their amounts, but now. Do the patients feel enough benefit from you to come in and pay that extra?

And that’s what we call balance billing. This is where you don’t get a surprise. Balance billing is, or it can be a surprise when a patient comes in and they thought, Oh, I thought I was only going to pay 50, but it turns out they owe 250 because balance billing is the amount left over from what the insurance paid.

And that difference again, out of network, please be mindful, make sure the patient’s fully aware of your fees. Let them know our service is 100. Your insurance may pay some part or none of it. And so ultimately, you may owe us 100, but let’s say one patient’s insurance pays 20, that patient owes you 80.

Another patient’s insurance pays 50, they owe you 50. In other words, you’re still getting your 100, just different amounts from the patient depending on their plan. This is why I often will tell people that insurance is an aid. It’s going to help pay for some of the care, not all of it. But if I can come to you and only have to pay 50 out of pocket instead of a hundred, what I’d be more likely to come in is the, is it there?

So that’s balance billing. Balance billing is like coinsurance, if you will, but it’s what’s left over when you are out of network. Now you’re going to see some where you’ll find, they’ll say it’s an out of pocket maximum. This you’ll see maybe towards the end of year. Let’s say you have someone that’s had.

Pretty good sized illness, went to the doctor for something significant. Once they’ve met that out of pocket max for the year, the insurance actually pays 100%. So your bill of 100 will be paid 100. But one thing to keep in mind, this 100 percent is not of what you billed. It’s, again, always what they allow.

So if you’re in network, great. If you’re out of network, it may or may not cover the full amount, but at least they’re no longer going to put it into a place of The patient has extra co pay. Now they may have extra co insurance out of network. So out of pocket max just simply means once they’ve hit that, that plan continues to pay.

These are ones that are good, particularly you might see towards the end of the year. Now here’s an important one. Where’s an assignment of benefits? This is block 13. You’ll see it towards the top here. And it says insured or authorized person signature. I authorize the payment to be made to the provider of service.

This is how you get the money. If you leave that blank, block 13, the money goes to the patient. So make sure your claims are assigned. If you don’t assign the benefits Check goes to the patient. So if the patient’s paid you in full, no problem. Let them get the money. But if they haven’t, please make sure you’ve done the assignment.

Keep in mind, unfortunately, if you are not part of Blue Cross and Blue Shield, often the assignment Won’t apply. Now with other insurers, they have to follow it, but Blue Cross Blue Shield is exempt. So keep in mind if someone has a plan Blue Cross Blue Shield, you’re out of network. Chances are it’s better for them to just pay up front and let them know they’re going to get the check from the insurance.

That way you’re not chasing after it. But assignment means they’re assigning the payment to be made to you. Simply block 13 puts signature on file, meaning they’ve signed an assignment that’s in the file. Now when we hear the term self pay, Well, what does self pay mean? Well, someone could have insurance, but they may not want to use it.

So they’re just a self pay patient. This is a patient that says, I just want to pay cash. But can a person who has insurance be a self pay patient? Actually, yeah, this is the United States. If a patient says, I don’t want to use my insurance, do they have a right to do so? They do. One thing to keep in mind though, if you’re in network, can they make this choice?

Yes, but make sure the patient signs a document in your office where they’ve said it. And agreed that I understand I have insurance and you’re a member, but I do not want my insurance to be billed and I will pay out of pocket, understanding that I will not want my insurance billed by you or by myself.

In other words, they’re saying they want to be a hundred percent cash patient. Nothing wrong with that. You know, one of the reasons people may want to do that, do you know records can always be kept private? No one can get access as long as you pay cash. The only time an insurance company can get records is if they paid for it.

If you will, but if a person has paid cash, they can completely hold them out. But this could be the case where somebody just goes, my plan is terrible. I’d rather pay your cash rate. Well, nothing wrong with that. Now, this brings me to what about offering cash discounts? We’ve done some other programs with that, but you’re going to often see now for acupuncturists, something called a discount health plan.

These are not insurance. I want everyone to bear in mind, but what it does, it kind of creates your own little PPL. The patient joins this discount health plan. You’re also a member. Now you can offer them a different price. In other words, like the insurance offering a discounted rate, you can do the same.

So for those of you who want to offer steeper discounts for cash. Well, you know, you can’t unless you’re in California. But otherwise the best thing to do is maybe get into a discount health plan. The patient joins that. Now it allows you to offer like an insurance. Think of it. How is it that an insurance says you can’t give a cash discount, but yet when you join ASH, they cut your fee to a third.

Well, a discount health plan is your way of kind of doing that. You just have to make sure the patient’s willing to participate and understands it. Realize someone with a discount health plan may come to you and say, do you take it? No, not unless you remember, but this is a way that has been used to help people get care.

Particularly when they have high deductibles or have very bad insurance or no insurance, it can offer it in a way that it makes it affordable and changes it from your regular amount. And when we talk about regular amounts, what are we talking about? Usual, customary, and reasonable, UCR. This is the average amount paid in your area.

I’m going to suggest take a look in your geographic region, take a look at your Medicare rates, take a look at what you see other providers charge, and kind of get a feel for it. Am I way undervaluing or overvaluing? I’m going to suggest go back to our other video that we did on relative values. But my concern is many offices often charge below, not understanding.

If you’re going to sell a house, wouldn’t you look at the neighborhood to see what what are houses selling for? Because what if you’re going to sell your house at half the price it’s worth? Well, you’re going to sell it. But it’s way below market. You’ll sell it in three seconds. So be careful of undervaluing, but also overvaluing.

I want a way for you to look at your fees to make sure they’re fair. That’s what I do for our network members, network members who join. That’s one of the first things we do with a meeting is to go through. Let’s look at your fees. Are they reasonable? I will tell you my experience. Acupuncturists bill eight or nine codes regularly, probably up to eight or nine, six.

I’m going to tell you half of you have fees that make no sense based on your usual customer and reasonable. So what if someone says your fee is too high? If you go through this properly, your fee will never be too high because you’ll know what that fee is going to be. I’m here to help. The American Acupuncture Council is always your advocate, as am I.

We do that one on one service I mentioned. If you really want to get some help to really make your business thrive, come and see me. I look forward to seeing all of you in the future and keep in mind, we’ll be doing something later. Uh, there’s going to be new codes beginning October 1st for diagnosis. We have seminars for that as well.

Talk to you soon, everybody. Best wishes.

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VA Community Recoupment

In fact, I’m sure a number of you have heard about what was going on with the VA community care and doing recoupment for some billing that you’ve done for cupping.

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Greetings friends and colleagues, welcome to another episode where we’re going to give you help to get paid to make sure you’re not paying anything back. In fact, I’m sure a number of you have heard about what was going on with the VA community care and doing recoupment for some billing that you’ve done for cupping.

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So let’s go and go to the slides. Let’s talk about this. What’s going on and what’s happening. I’ve got a lot of good news and I’m really happy to share that with you. So obviously a lot of you are treating and billing for VA patients. They are great patients. They need a lot of help and it’s the one insurance that does cover cupping.

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So you can bill with cupping and we have been billing with the unlisted code having no problems. However, something came up. I had an office that came to me and said, Hey, Sam, I’ve got a problem. I received a request for recoupment for billing 97039 for cupping and the indicated dates all the way back to 2022.

And I thought, Hmm, okay, interesting. But I thought, how much are they asking for? And I kid you not. This particular office was a heavy, heavy VA office and they’re wanting close to a hundred thousand dollars back. Now you’re thinking, how can that be possible? Well, let me tell you, they treat a lot of VA patients and they paid pretty well for cupping.

That’s what they were coming back for. So there was obviously a lot of panic. Wait a minute. How can they come back? And ask for something they’ve already paid for. That was really part of what we were doing. So in the VA, they have something called the standard episode of care specific to acupuncture. And what these are, are a listing of the services that you may provide an acupuncture patient.

Without any additional authorization, this includes E& M codes, lots of therapy codes, it even includes laser now, but it also includes codes for cupping, and before was codes that listed unlisted. So this is a very current one. You’ll notice this one is dated April 9th of this year, and you’ll notice I’ve highlighted in red the codes that they are allowing, and you’ll see here the first one that’s for laser, But it’s got dry needling.

It’s got 97016. By the way, that is the code you should be using for cupping, 97016. And you notice you just go along manual therapy. And of course, all the acupuncture codes, what you’ll notice is missing. is the code for 97039, the so called unlisted code. It’s an unlisted modality, and many people had used it for cupping, and I certainly recommended it.

It paid well. It just allowed you to describe it as cupping, and we were paid for it. Now, again, you’ll notice this is the most current acupuncture authorizations. You’ll notice, again, conspicuously, there is no 97039. or even the 97139 which is again unlisted codes. Well that’s what they’re coming back for and you notice for each of them whether it’s going to be the initial care plan or the follow ups for chronic care even you’ll notice it’s missing.

However once I received this I said hold on a minute This cannot actually be correct. And the American Acupuncture Council, because of course, a lot of you are insured through them, we began to work in the background to say, this is improper. So we got the attorneys involved, myself as the coder, and we said, wait a minute.

We went back and researched and specifically the standard episodes of care that they’ve published through the, uh, VA from 2021, 2022, and 2023. did indeed list the code 97039. So being it’s part of the standard episode of care and it was allowed during all phases, whether initial continuation of care or chronic care, it was there.

So now they’re coming back saying, well, we know we published a code, but we’re saying we shouldn’t have had it and we want the money back. Well, that certainly doesn’t seem to be proper. So what we did, the American Acupuncture Council and myself is to start to have our providers respond back to them with this letter.

It says, I received a refund request for 97039. And it dated all the way back to dates of service from 2022 as being overpaid. And we’ve researched it. The schedule, the standard episode of care specifically shows from 10 18, they all allowed this code. Now I will keep in mind that they did eliminate it.

And I think this is where the problem began. Because it was eliminated in February, they said, Hey, we’re going to go back and look prior. Well, you can’t. Obviously, if you build 97039 after February 23rd, technically that would be improper. And they could recoup it, but any dates prior, it was part of the standard episode.

So, per the published guidelines of the VA, it says, repayment appears improper because the code was in the SEOC, we identified it as cupping, and per the guidelines, when there’s no specific code, Because even the code I’m recommending, 97016, doesn’t actually indicate cupping. It says vasonomatic device, which would technically be correct.

But you could use either, and they were paying it. So we’re pushing back, saying, well, there was no overpayment because the code was properly identified as an unlisted service and the dates of service for the code should have been paid. We, in fact, even went further and talked about recoupment in that when an insurance pays you for something that they later determined was paid improperly, Even if they shouldn’t have, case law says that they can’t go back for it.

And so really we pushed back in a lot of ways. So everyone panicked. I said, hold on, let’s see what’s going to happen. Well, about a week ago, actually a little over a week ago, this was Optum’s response. It says Optum’s claims department worked on a special project intended to remediate historical claims logic concerns, which impacted unlisted procedure codes.

Although our analysis of the Unlisted Procedure Codes is ongoing, the current recruitments are in the process of being voided. So all those ones they sent letters, now being voided. If they haven’t, go ahead and push back. We sincerely apologize for this inconvenience this has caused and appreciate your patience as we work to void these previous specific recruitments regarding the Unlisted Procedure Codes.

Additional communications will be coming. So in other words Oops, we made a mistake. That’s why often be careful. And that’s really why we do the network is to be there to help with this type of issue. When someone joins the network, not only do you get seminars, but you get this type of help. Quite frankly, this doctors, this office that had this issue.

Literally paid for a hundred years of the network based on what we charged, based on what was there. And realize though, network members, we’re going to get it to you first, but always know that we’re going to be here to support. If you had went to our website, which is the AAC Info Network under News, on July 25th we posted this.

So I want everyone to kind of calm down and say, wait a minute. The unlisted code should have been paid because it was part of the standard episode. From this point forward, do not use 97039. From February of this year, cannot. Now, for those of you that attended my VA seminar earlier this year, you heard this information.

You knew it was changed, but again, they can’t go back and recoup. As always, we want to be your advocate because Your success is ours. The American Acupuncture Council is really your partner. We’re always here to help. And that’s why we do the network where you can work one on one with me because members, I gave them this letter directly.

So if you’re a member. of our AAC Info Network. Now not insured, insured is your malpractice, but members of the network, if you’re still running into this issue, just reach out to me and I’ll send a letter to you. But I’m going to highlight this is going to be for members only. For others, you may have to go back and read it, but it falls in the same category.

Our goal, keep you going, keep you doing what you do well is to help people. And when people want to come after you, we’re going to be your line of protection. Until next time, everyone, this is Sam Collins.

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Acupuncture Malpractice Insurance – Insurance Verification

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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.

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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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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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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.