Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hi everyone. Welcome to another episode with the American Acupuncture Council. I’m Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council, as well as the profession in general. This episode is gonna deal with a very common question that I get whenever I’m teaching a seminar or doing our network services.
People always ask, Hey, Sam, I got a payment. Now the insurance company is asking for money. What can I do? Is there anything I can do to fight this back? What if they recoup the money? There are many things you can do, and there’s laws and statutes that are on your side. Never assume what they tell you is correct.
Let’s face it, you do an insurance verification, you bill the insurance, they pay it, and then they come back later and say, Hey, we paid you money six months ago. Turns out we shouldn’t have. So let’s take a scenario like that. The insurance company pay. . Then they come back and say, Oops, we shouldn’t have paid because there were visits that were applied towards the whole overall benefit.
Maybe it’s combined with chiropractic, maybe with physical therapy, and now they want it back. What are our rights? What do we do? So let’s go to the slides. Let’s talk about what laws and things protect you in understanding how we have to deal with this. This is not uncommon. Now, I don’t want this to scare you off.
This doesn’t happen a lot, but it happens enough. You have to know what your rights. What are my rights when someone says, We shouldn’t have paid you and we want this back? So here’s a letter and please note everyone, this is a letter from Federal Blue Cross Blue Shield and notice what it’s saying. Dear Billing Department, they’re talking to us directly in regards to the request for repayment for claim.
The request made to you was a voluntary overpayment request. Because you are in network provider, you do not have to pay back any overpayment if the overpayment was discovered 365 days or more after the claim was finalized. So I wanna take a look at this letter and notice what they’re stating here.
They’re stating that they can request an overpayment if you are in network, but not if it’s over 365 days. So notice that’s why the letter says a voluntary overpayment realize most often when an insurance company is requesting a re. they’re doing. So just to see if you’re willing to pay it. So by example, let’s say a policy, as I mentioned, has 20 visits per year.
You verify it and they pay it, and then later they come back six months later, a year later and say, Oops, it turns out the patient already had visits with some other provider. Therefore, we shouldn’t have paid you. Frankly, whose fault is that? You did the proper verification, you bill it, they paid it.
Now they’re saying, Oops, we made a mistake. We want you to pay it back. So notice that’s why this says voluntary. So even though this provider is in network, they’re saying please pay us back. My issue is gonna be no thanks. Why should I pay you back if it’s your mistake? In essence, what they’re saying is, we made a.
And the patient’s benefits weren’t there. Therefore, we want you to pay back our mistake. My rule would be, no, you go to your insured, That’s who you made the mistake with. Cuz essentially what they’re trying to push you to do is you pay them back and now go after the patient. Why would we have to go after the patient if that’s your insured?
That’s where you’ll notice the difference here. Notice it says here, the request made to you was volunt. And because you are in network and it’s over 365 days. So notice now the difference if they had done this within 365 days because you’re in network, they can take it back. This is one of the downsides of belonging to an insurance you give them to right to recoup.
Even when the error wasn’t yours. It was their own mistake. So it’s one of the downsides of being in network. Now, if you were out of network, could you just completely refuse this and say, Actually you could in the absence of fraud, where something you build wrong or maybe they paid you twice, you are under no obligation to refund this.
I’m gonna point you to this is a letter that we use for those in our network, or those that come to a seminar that deals with an insurance company that has paid you and then subsequently wants it back. So notice at the top it says, We received your letter where your company’s requesting re refund the payment, and you reviewed the benefits and nothing here shows otherwise.
So let’s move down here. It says, I feel that you have do not have the right to place this burden upon my office by asking us to correct your error. And this is backed up by Case Law. Notice it says, I would like to bring your attention to cases involving the Federated Mutual Insurance Company, and essentially it says the insurance company is in the best position to know the policy limits and must bear the responsibility of their own mistake.
So again, if you’re out of network and the insurance is asking for this back, understand if they made the mistake and paid more than they should. Maybe there was a deductible, they didn’t apply or they just applied more visits than the plan allows. They have to bear the responsibility for it. And again, case law noting dating back to 1974, so for many of you may not have even been born yet.
The next case goes from here for national Western Life Insurance Company. And it says in the absence of. A healthcare provider is not legally obligated to run refund payments. It receives from an insurer if the insurer subsequently determines they were paid in error. So let’s do this example. You call, the plan says they cover acupuncture.
Great. You bill it, they pay it, and then six months later they say, Oops, it turns out we don’t cover acupuncture. Whose fault is that? You did everything properly. What they’re saying is, pay us back and you chase the patient. My rule would be, You go after your own patient. That’s why that one said voluntary.
You’re under no obligation to pay this. So when you were out of network, , you may completely push back on this with citing these two case laws, because if there’s nothing wrong with the claim, you didn’t bill anything in error. There wasn’t something billed that you didn’t provide, or they didn’t pay you twice.
If someone pays you twice for the same data service, you do have to refund the overpayment of that. But outside of that, the answer is absolutely no. Again, if you’re out of network. Now, why is it different if you’re in. It’s different when you’re in network because part of the contract we sign, when we join these insurances, it literally says in the contract, Should we make an overpayment?
Even if the error was on our side, we can recoup the money. And I’m sure many of you, almost Sam, that’s happened to me before. They just take the money from another patient. They will if you’re in network. If you’re out of network, they should not be because they have no right to that. In fact, the case law stands up, but let’s talk about if you’re in network.
Notice it said one year. Now that’s the federal statute, which is generally equal to what the billing time is. So if the billing time is one year, they have one year to recoup again, if you’re in network. So if you are in network, they can recoup. Within the timeframe of the statute of limitations, and that’s where this is a little bit different from state to state.
So I’m gonna give you a little breakdown here. This has every state, and you’ll notice it can vary from some, That’s one year, 36 months, five years, two years, all the way down to as little as 30 days for some. And some states don’t have any, which to me means it defaults to the federal statute. But always know the statute of limitations.
Just like an insurance. You know how some insurances are? You have 30 days to bill 60, 90, or one. The same thing applies here for a recoupment. The state law will break it down. So is it one year or otherwise? So know your state and whether or not you can push back. My rule would be always send a letter like this in a response when you are out of network.
Even in network, I would use the same protocols, but then follow up with the statute of limitations. Do not be. To push back. The assumption is often you don’t know better and are just gonna pay, cuz we’re afraid of the insurance we’re gonna get in trouble. If they could recoup it in network, they probably would’ve.
So take a look here. Here’s an Aetna claim, and notice what it says As a result of a routine claims payment, we previously notified you that there were some differences between the amount paid and the amount, which you should have been. That’s their own issue. So notice and I highlighted it in yellow, it says, Our records indicate the overpayment as noted on the enclosed document, is not eligible to be offset from future claim payments.
In other words, you’re outta network. So we can’t force you to pay it back, but we’re gonna please say therefore we must request you issue a check or money order payable to us in the amount that’s requested. You know what my answer to that is? No thank. Why would I voluntarily send it? When do they ever voluntarily say, Hey, you know what?
We’re not paying you enough. We’re just gonna go ahead and pay you more. Know your rights. Don’t be afraid to push back when there’s a request for overpayment. Was it truly overpaid? Did they pay you more than you billed? That you would’ve to pay back the amount over what you build? Or if they paid you twice.
But if you’re out of network and they later decide, they didn’t feel they should have paid it too. That’s on them. They should know their own policy. And the Statue of limitation applies for those of you who are in network, just like they put a limit to the time that you can send a. They will have limits to when they recoup.
This is why a lot of providers think maybe I don’t want to be in network, cuz I give them a little bit of power that’s part of that tradeoff. We did this in an earlier talk with you of trading off what is it worth it or not. Now this doesn’t happen enough to where it’s gonna major problem, but it’s something to note within your rights because many times they’ll just send you a letter hoping you’ll pay.
Let’s say you send a hundred of these letters out, maybe 50 of the doctors know the rule. They’re not gonna pay it, but the other 50. That’s an easy way for them to recoup money by simply having people not aware of what their rights are. Notice. These plans aren’t necessarily there for you. Always be able to push back and know where the laws fit.
That’s what we’re here to do. That’s what the American Acupuncture Council is there to do. We always wanna enhance your practice as I do. For those of you who would want to have help, just what we’re doing now where we can deal with this one-on-one via phone or Zoom or otherwise, you may wanna join our network.
Take a look at our site. You can do the QR code or go directly to our site. Remember, it’s aac info network.com. We’re always here. The American Acupuncture is always going to be your resource, your place for help. And remember, first of the year is coming. What’s gonna be changing, lots of things, codes, fees, and otherwise probably time to get to a continuing education seminar with the American Acupuncture Council Network.
I hope to see all of the future date. Until then, best wishes everyone.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
All right everyone, and welcome to another edition of To The Point with the American Acupuncture Council, and thank you to the American Acupuncture Council for this opportunity, but also as an opportunity for you to get more information about how to make sure you can run a well run, well-rounded practice, one that you enjoy doing, one that can also be profitable.
On today’s topic, what I’d like to discuss is manage care, joining an insurance. Let’s go to the slides. Let’s talk a little bit about that. Cause it’s a very common question I get as a coding and billing expert and doing this for a number of years with seminars, one of the main questions I get for members is, Hey, should I join this plan?
Is it worth it? What are the good ones? Which are the bad ones? And what I wanna do with this is try to give you a little bit of a primer on what you should do or understand when you join or think of joining, what are the things that you must consider? So managed care plans, I like to think. Is it worth it?
Is there a value to join or not to join, if you will, is the question. So let’s focus in, Let’s really talk about what we mean by the term managed care. Often, I think we misunderstand it, but in many ways managed care just means that the insurance company is truly managing the providers you’re joining.
And you’ll often hear these terms like a preferred provider or a member provider. And these are often what we call ppo, preferred provider organizations or HMOs. And these are plans that the patient is given incentive. To see the doctors within the plan, generally with lesser copays, deductibles, or within hmo.
Of course, it means if they go someplace that’s not in the hmo, there’s literally no benefits, so we have to look whether or not this is worth it. So here it says, insurance plans that provide or that have the provider acupunctures to join in order to gain access to get the insurance payment. Sometimes remember, You can be outta network, and this is one of the things to consider.
Do you have to join an insurance to be paid by it? And let’s make this clear on a regular insurance plan. Once you are licensed, you may bill and access benefits. Unless the plan has a provision that they only pay for providers in network. Be very careful. A lot of people when they first start will think, Ooh, I have to join.
In order to gain access and you don’t. So first thing is make sure, does the plan have benefits that are out of network? Meaning any willing provider or do they require in network by example? Some of you’ve probably have seen these Medicare Advantage plans, Part C plans. They’re advertised quite heavily right now.
Pay attention to on television commercials, and you’ll see companies like United and Cigna and others advertising that there’s acupuncture benefit. Bear in mind, many of these plans don’t require that you join as a provider. Just be willing to accept the patient. Now, when you do accept the patient, you’re gonna be limited to their fee schedule, but at least that way gains access without joining.
Now, the other side would be, if I join, would it be more likely for the patient to come to me? Does it incentivize them enough to choose me as the provider? So again, the provider gains access. But we have to make sure, is that access we could have already had. The real issue here, I think that we want to consider is your business is that it’s a business.
I know it’s a practice and you’re there to help and all do all the good things to care for someone, but at the end of the day, it’s still a business. So like with any business, we have to make a business decision on this type of plan. There is a trade off. What is the trade off? The trade off is if you join, you gain access.
In other words, the patient has incentive to see you. Now, for me, the big issue is does the patient have complete access or is it one that they could still go anywhere? So the bottom line though, it gives you access. It allows the patient to come and see you and have a benefit. And let’s face it, people who have insurance are more likely to go to the doctor than those that don’t.
I’m sure you’ve all witnessed that. You all probably know someone right now, maybe even a family member that needs to go to the doctor but is not going because affordability, they have no insurance, no benefits. They’re not going. So this often is why people with insurance generally go to the doctor more because frankly they have access.
Always think of what’s the barrier to care. Often money. So this may help with that. However, talking about money, the trade off is yes, you may get more patients or at least more access. , But do you get paid? You’re saying money. No, you don’t. Mostly, and I’ll say every time you join a plan, there’s always a reduced or limited reimbursement you can collect.
Now, that reimbursement could be decent enough that it’s worth it, but it may be too low. So one of the things to consider is there enough value for me to do it? In other words, the choices can, the volume. Make up the difference, and in some ways, think of managed care, and this sounds awful, but Managed Care, in my opinion, in some ways is the 99 cents store.
The 99 cents store is a very popular store, but how does that store really function? They have to sell a very high volume of goods because they’re only 99 cents. So you have to think of it when you’re getting reduced payment. Your volume has to go up. Now, this is something that’s a little more complicated for an acupuncturist.
Say, compared to a chiropractor, you have to provide all the services that you deliver in a acupuncture, excuse me, in a chiropractic or physical therapy setting, they can have assistance. Acupuncturists are pretty much out of the loop on that, so it means, for the most part, you have to do everything, all the care, and of course, your care is very time.
I. , Let’s face it. Each set of needles is 15 minutes. And while the eight minute rule does apply, even if you’re doing three units, you’re spending close to 40 minutes, maybe 45 minutes with that patient in your. That’s a lot of time if you’re only getting a very minimal amount of reimbursement. So you’ve really gotta kinda weigh out the pluses and minuses.
And what I think you should do is start to really to look at these plans from a true business standpoint. Like just when you take your first business course in college, one of the things you learn is, Hey, can you make a widget? How much does it cost to make the widget? How much can you sell it for? And how many can you sell?
That depends on how profitable the business can be. So what I’d like you to do is keep it relatively simple. Get a piece of paper, draw a line down the center on one side, put yes, one side, put no, this is exactly what I do with my network members. It can be a little bit more detailed. Obviously in this form we’re limited, but this can give you a good starting point.
Am I gonna join something? The yes would be if it’s exclusive. If the patient has no benefits at. Without you being in the plan. To me, that’s a big yes to join because otherwise there’s no access. What if you’re in an area where there’s a group where a lot of people in your area belong to it?
Would you likely wanna join? Because if they can’t come to you with their insurance, are they still gonna come in or are they gonna choose elsewhere? So an exclusive plan to me is a big yes. However, keep in mind, what if it’s non exclusive? And be careful. A lot of PPOs prefer provider organiz. Are not actually as exclusive as people think.
An HMO is one where the patient has to go within the plan, but a PPO is one where the patient can still choose to go outside of it, and you want to check to see if I join, could the patient still come to me? One of the things I will be concerned with is often people join these plans and all of a sudden realize, Hey, I’m getting less money.
I’ll give an example. Sigma Insurance has done this. There’s a group with a SH that if you join. You get a limited reimbursement, but if you’re out of network, your reimbursement’s the same but or is higher actually. So from that standpoint, often you really wanna look to see if it’s not exclusive, what type of access does a patient have?
And here’s another example. United Healthcare generally will pay providers better that are out of network. And you’re thinking that doesn’t make sense. That’s how the plan works. It just pays more. Now, the difference could be though, maybe they don’t find you because you’re not in the network, or sometimes their deductible could be higher for out of network providers.
So I look first, if the patient could come to me anyway, what’s the incentive here? So you have to look at what’s the balance and how’s it gonna draw someone in, because at the end of the day, it comes down to if I’m gonna join, even if it’s exclusive, is the pay reason. Does it pay me enough to really make it work?
Bear in mind, there are some plans for acupuncture that I kid you not pay as little as about $40 per visit, and that’s all inclusive. I don’t care what you do, you can do five sets of needles in a therapy or two sets of needles. You’re still getting, the $40. And also keep in mind, this is something that surprised someone the other day.
They had a plan that pays 63 42 with a $25 copay. And they had the mindset that the plan was gonna pay 63 42, and then you charge the patient 25 on top of it thinking they were gonna get close to $90. The reality is, in a plan like that, when it says it pays 63 42 with a $25 copay, they’re going to allow 63, 42 minus the 25 that the patient pays.
So the total you. Is 63 42 with 25 of it coming from the patient. So we have to look even at that amount. Is that reasonable? Is it enough for me to really make my office work? What if it just simply pays too little? know, You look and go, I can’t do that. Work for it. You know yourself as a practitioner, some of you could spend maybe 20, 30 minutes with a patient.
Some of you might spend an hour or. The more time you spend, the more value to the service. You can’t really survive. If you’re seeing a patient for 40 bucks and spending an hour or plus, I don’t think you can keep your practice helping. Let’s face it, that means you can make a max of maybe 300 a day, and I’m not sure $300 a day is gonna keep enough for your office as well as your home expenses.
The other fact to think of though is what if I joined? Does it bring me many new patients? Would it give me access to people who otherwise wouldn’t? That’s something to consider. What if all of a sudden you can get many more patients? Realize if an increase in volume happens, then that could still increase the bottom line cuz you’re seeing more people.
The limitation as an acupuncturist though, is how many people can I see per day? There’s limits there. There’s only so much time in the day. If you spend an hour with every patient, all you can see is eight and eight hour day anyway. So something to think of. But if it brings a new patient, I think.
That’s not a bad thing. You know what? If this is a new patient that you wouldn’t I otherwise see? And bear in mind, I had an office once that said, Sam, I’ve joined these plans because when I join, these people come in. But they often refer me people that aren’t part of the managed care plan because they have friends.
And so I thought, Okay, tangent. Generally I can see where there may be a benefit there, but those are all the things to weigh out because bottom line, what if they’re already a current patient? And this has happened to me. I had an office that they joined. And they were getting a hundred plus per visit.
When they joined, they got dropped to 60 and I thought, didn’t you find that out before joining? So before you join, really ask the hard question, What does it pay? Realize, because of the no surprise act, the insurance company have to be forthcoming with what they’re going to allow. So be careful before you join, really start to weigh out all these factors, and you may look at some other things as well.
Sometimes these plans, as America Specialty Health, may request that you send pretreatment author. After a certain number of visits. Now, I won’t say those are very hard, but that’s a lot of extra work or at least extra work that you have to do after five visits. Is that worth it when you consider the time that it takes to do it Now, what if it even only takes 15, 20 minutes?
That’s still time. So again, we have to weigh all those factors in. Now, if it has a lot of things that you’re required to do, maybe. If it’s relatively simple, and again, you have to learn to make it work and understand what they’re looking for. But you can see here this lens toward be a little bit more scrupulous.
Don’t be afraid to be a little bit more focused on is there enough value here? Now, the good news is, let’s say you join something and it turns out to be horrible, and you’re like, Oh my God. You can always drop out, but bear in mind, dropping out is not immediate and be also conscientious that when you join something, always ask.
What other plans will this join me to? By example? If you join a group like multi plan, it’s not just one. It often attaches itself to several things and be conscious that you can sometimes opt out of these types of plan. You can say, Okay, I wanna belong to this one, but not that. So by example, with some as H policies, you can choose to opt into Blue Cross, but not Blue Shield or Cigna and not Aetna.
So before, always look at what do I really want to join? What’s good for me or what’s not so good and see about opting out. At the end of the day, it’s all about the value, The business value, I would say. Think of what your cash rate. Cash rate is meant to be simpler, less because there’s less work. I’m not saying insurance coding and billing is hard, but there’s more time.
So often for cash patients, we’ll offer like 10% off because know, we don’t have all the other background paperwork. Okay? So think of that rate. In my opinion, I need at least that to be darn close to what my cash rate is. Now, obviously I don’t think anyone has a cash rate as little as. So I’m looking at 60 or 70.
So a lot of these plans I look at and go, I’m not so sure unless I can really make it up in the volume. But I wanna look at does it match that, or at least this, Have you ever thought of, what does it cost to treat a patient in your office? Really, know, what’s your bottom line? What does it take for me to just keep my office open?
Now how do we do that? What I’d like you to do is to take your office over. What does it cost for your office? And that includes your rent, your lease, cost of needles, table paper, everything to rent in your office. You know what I’d actually include with that? I’d include student loans. I really think that’s part of your office cost.
But anyway, take your overhead, then divide that by the average number of patients per month. Notice I didn’t say, or excuse me, patient visits per month. Not patients, but patient visits. So by example, let’s say your overhead cost is $4,000. That’s what it costs to run the office, and 25 visits per week or a hundred per month.
That means in order for you just to break even and pay for the office, you have to get at least $40 per patient. So when you’re looking at a plan like an ASF that’s paying 40, you’re making nothing. So unless you can increase the volume, this really doesn’t help. So be careful before you decide to choose.
You cannot do this at a loss. It’s gotta be with some level of profit. Now, maybe you can have an office cost that’s only $15 or $20 a patient. So some things to consider, but I really want you to look at the business side of it, and this is the part maybe we don’t like doing. You want the school to be an acupuncturist.
You are good at what you do. You help people. The part we don’t like is, What do you mean I gotta deal with the business end? And that is an important part because unfortunately a lot of acupunc. Within three to five years of graduation, don’t practice because they simply couldn’t deal with the business side of it.
And I want to help you with that to say, could this make a difference? Now what if you join this plan and though it doesn’t pay very much and that doesn’t meet the overhead expense, but what if you have an office, you’re not very busy, and you have openings for another 20 visits per week or more.
I would rather fill them with these than not have them at. And then maybe you can build the practice from there on other referrals and get them sold on maybe maintenance care. So there’s some things to consider here, but I want to be careful that if it’s gonna take away an existing patient and all of a sudden now you’re replacing a hundred dollars patient with a $40 patient, not a good idea.
Realize that under ash, depending on the plan you join, whether it’s Cigna or others, the reimbursement can be as little as 40 to about $90, which means in this aspect, you could be making $0. Actual profit to maybe 45 per patient. Now that’s not awful, to get 45. In fact, I think we can make overhead a little bit lower.
So let’s take a look at like Ash with Cigna. And I’m gonna say this varies from state to state. I’m giving you just one state here, and you’ll see here they allow 51 for the first set, 38 for the second, but it’s just a maximum of two. Means you’re gonna get $89, you’re not gonna build multiple sets or therapies.
They’ll either pay two codes and the max is 89 per day. Now is that. No, I think that’s reasonable. I think that fits a lot of people’s cashes too. Two sets, meaning you can do it 30 minutes, they do pay separately for exams. But let’s be honest, notice the exam price are only 20 to $40. So when you’re getting managed care, you gotta know that I’m gonna get probably less than a hundred dollars per visit.
Can I make that work? Does the volume hit it? And remember, this is an ash tier. When you join Ash, and I’m not saying this is negative for ash, I just wish they paid more. Most acupuncturists when you join is gonna be put at a tier three, which means when you’re a tier three, after five visits, you have to send more information about the need for care from the patient.
Now, as you’re in the plan for a length of time, you may reach a tier six where you don’t have to do that because they know that you’re trustworthy. You’re not over utilizing. But you can see here, there’s extra work. Now, again, I’m not against it, and there’s ways to work with that. That’s one of the things I do with our network services to help you with that.
But I want you to also look at this overall and know yourself. If you know that you spend more time, if you know that you do not like to do extra reports, this may not be for you. You’ve really gotta make the hard choice of is there enough value for me? I’m not against joining, but take a look at the plans and what the incentives.
How does it increase the volume of patients? Does it bring in 10 general patients? So let me give you a kind of a quick primer about what must or should you join. I’ll never say must, but these are just my opinion. I will certainly say if you’re joining the va, that’s a win-win, meaning there’s no negative to that, in my opinion.
If you join the va, whether you’re on, Texas or west of Texas or East with Optum, Tri West, or Optum, when you join, there’s no cost to join. And the only access is to VA patients. Now, if you get a VA patient, it’s great that VA patient’s probably gonna equal 1500 to $2,000 of reimbursement for the amount of services they offer.
So I’d say, Okay, there’s a value there. There’s no downside, because if you join the worst thing that happens, you don’t get a patient. If I get just one or two a month, that certainly could be worth it. So I think for me, there’s no issue there. I think HMO plans like Medicare Part C. Now notice I’m saying Medicare Part C, I’m not talking regular Medicare.
I’m talking the Part C policies with the additional acupuncture benefit, those I have no problem joining because again, this is exclusive. If you’re in, you can see the patient and these can actually decently reimburse. They give access not only to acupuncture, but to exams and therapies as well. So those I have no problem.
Again, no cost to joining. What about optional plans? You know what? If I wanna join an a sh or Primera or Blue Cross Blue Shield look to see what does it do, what else does it join you to? I would start with, is it exclusive? Is my number one issue. Cause I think if I wanna bring people in, think of how many times you’ve had a patient come in and has this ever happened to you?
Have you ever had a patient that you gave a hardship? that you hardly charge ’em anything, but you wanna be helpful. That’s what you do. And in turn, that patient wound up referring you many patients. So realize there’s more benefits that could be there, but you wanna start to weigh that out. Is there enough value outside of this?
I’d really have to work with the individually to say, Okay, let’s talk about what area you in, What part of the country, what county, what city? Who is insured there? What type of plans are you seeing? Is there enough a benefit to do it? Does it pay enough? Now, as you can tell, this is complicated. The good news is you’re never stuck, but you do wanna make some choices and decide whether or not it works for you as a business provider.
At the end of the day, you are providing a service that has a value, and that value has to be enough to pay for you and your office, but just your home cost as well. So it’s something to consider. I would say certainly take some time to look through it. Don’t be afraid to be a little scrutinizing, and if you jump in one.
Don’t like it. You can always jump out. Keep in mind though, one thing, you can join one plan and not necessarily have to join the other. So when you join like a sh, make sure you know that. Can I opt into one plan? Maybe I belong for Cigna, but not for Ner or some of the others. So keep in mind to always look at all the aspects of whether or not, what do I have to be in?
What am I automatic or what are optional? Cause I would certainly not wanna be part of personal injury or some of these other things that may be involved with them. And that’s what we do at the American Acupuncture Council Network. For some of you, You may have already been familiar with this, but it’s a chance for me to be part of your staff.
Give me a call, send me an email, do a Zoom meeting with me, and we help your office. Take a look here. Just go to our website or do this QR code. We’re here to help. We always want to have you to have the best possible practice you can. That’s really our goal. So we’re always here to serve American Acupuncture Council Network.
Here’s our phone number. Go to our website. I will say to all of you, best wishes, and don’t be afraid. Make that choice. Decide what works for your business. We’re here to support you. Until next time, everyone take care.
What I want to focus on is the medical necessity of acupuncture. How do we define it? What is it? And then how that leads to pre-authorization as I’m sure many of you have noted acupuncture has become very well covered by lots of plans.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript
Hi, everyone. Welcome to another edition of the American Acupuncture Council malpractice, To The Point, getting your practice better, making your practice improve on many facets. My job as always is to talk about the acupuncture and getting paid for it. How do we create that business model? Today’s edition.
What I want to focus on is the medical necessity of acupuncture. How do we define it? What is it? And then how that leads to pre-authorization as I’m sure many of you have noted acupuncture has become very well covered by lots of plans. Aetna now mandates it. I If you’re in Massachusetts, it’s mandatory on their coverage.
And of course there are five states with acupuncture. That’s mandatory, but many plans now are covering acupuncture, but let’s even go beyond that. What about a cash? I want to focus on a little bit on both of those in the sense of let’s talk about what is necessity, how do we define it? And then how do we use that to get pre-authorizations?
One of the things I deal with quite a bit, and being an expert on coding, billing, documentation and collection is, Hey, how do I get them to approve more care? Particularly if you do the VA. Premera or Ash, any of these types of plans. So let’s go to the slides of room. Let’s talk about the medical necessity of acupuncture and pre-authorization as always, there’s our website and there is my email as well.
Let’s talk about what is medical necessity of acupuncture? How do we define it? And I think you really have to look at it in two ways. It’s really the same, but two different ways you have the patient and you have the third-party meaning. If someone else is paying for it, if you’re paying for something you want to make sure there was service was provided and it was needed.
So from a patient standpoint, let’s think what does a patient need for medical necessity? I come to you. I don’t feel good. I’m in pain. What am I looking for to reduce my. So medical necessity for a patient is, does it work? Does it accomplish why went to which is an always pain management? Obviously acupuncture can treat more than just pain, but you get my point.
Let’s keep it simplistic on the pain level. Did it improve it? Let’s face it does pain medication. It does. You, if you take enough Vicodin or, something more S more significant what it reduced the pain. Sure. But then what is the outcome you’re asleep?
You don’t feel the pain cause your body’s knocked out. So does that really improve anything? So from a patient standpoint, they’re not just looking for pain, Redux. But improvement of their life improvement of their activities of daily living. And so from that standpoint things, but medical necessity for a patient is either they’re getting better or they’re not, if they’re not getting better, what did they do?
They stopped coming simple as that. When we deal with it from a third party, meaning someone else’s. Let’s say a parent is paying for a child. If it’s not working there to stop having them come well, insurance works the same way they want to make sure is the patient getting better. And I think this is where agriculturists often have a hard time.
Acupuncture works very well, as you all know, but I will go back to, did you demonstrate it that’s really going to be an important factor. How did you document that the patient got better is a statement. Like I feel better, really adequate. Think of it like a person. If you put someone on a diet and they go, oh my God, I feel better.
I have more energy. Those are good things, but what’s the purpose of the diet for the. Is to lose weight. So we need evidence of weight, loss, or evidence of reduction of pain. So let’s take a look at how does insurance define this, and this is an Anthem policy, their newest guideline notice just from this year.
And this was their typical acupuncture guideline. Now, with this, it gets a bit confused when it talks about medical necessity and mostly it gets into the types of things that they allow you to treat nausea, vomiting, chronic pain, and so forth. But I want to highlight this. It says the individual being treated continues to experience one or more of the conditions listed above and the requesting physician documents ongoing benefit from the use of acupuncture.
So what is going to be the. Or reduction of these how do we demonstrate it? Is it going to be enough to say I feel better? And I’m going to say probably not let’s take a look at like Aetna, here’s the epic policy when it comes to acupuncture and it talks about the types of things they’re expecting.
And the main thing they’re expecting is this, the plan of care should be ongoing, updated as a matter of hours, condition changes, meaning we have to have evidence of change and are considered medically necessary. Only if there’s a reasonable expectation. That acupuncture will achieve measurable improvement.
This is where I think we have difficulty. A statement of, I feel better is not really measured. So we have to somehow try to attempt to quantify that. And it says, of course the patient should be evaluated regularly. The bottom line is treatment goals and subsequent documentation should result in that.
There’s an achievement of a change. What if we’re saying a pain reduction, we have to stay to such by how even a numerical pain scale while not perfect, at least give some evidence of that. But I’m going to say to you that’s not enough when it comes to pre authorizing care. If you’re dealing with a premier Ash, a statement of reduction of pain is good, but they want a little more evidence.
So let’s take a look at what they all say. Maintenance treatment is where the member symptoms are. Neither regressing or improvement is considered not medically necessary. So keep in mind a lot of times you’ll say the patient’s not getting worse. And while I don’t disagree with that, they’re going to question well, if they didn’t get.
They not get worse. So we have to be able to have some ability to prove it. So this says here, if no clinical benefits is appreciated after four weeks, then treatments should be reconsidered. In other words, they’re not expecting the patient to be better overnight, but some measurable change will even Cigna gets in the mix here.
It talks about it’s protocol. What I’m showing you here is from each carrier. So that way it’s not just Sam getting opinion, but what did they stay that. They say standardized tests and measures a functional outcome measures. And it says measuring outcomes is an important component of acupuncturist.
Practice. Outcome measures are important in direct management of individual patient care and for the opportunity to provide the profession and collectively comparing their results to others. How do we know ours is better? We compare it. So here’s what it says. Second paragraph, the use of standardized tests and measures early in an episode of care, establishes a baseline of status for the patient.
Providing a means to quantify change in the patient’s home. Outcome measures along with other standardized tests and measures used throughout the episode. In other words, we’ve got to measure things. So be careful of, I feel better. That’s good. But when they say they feel better, I want you to measure it simply this way.
When you say your pain is bad, give me a couple of things that you can’t do or have difficulty doing because of the pain. And then as it improves, How have those change. So you want to start to think of, I want to use tools to make this easy and what I want to point out, this is quite easy. I would even say an acupuncturist could have mediocre documentation so long as you’ve documented the aspects of the care that was delivered, the time the services.
And ultimately the outcome, the biggest thing is what is the outcome of the patient? So I like to take ever, of course, behind the scenes for United Anthem and a lots of policies, including Optum. And here’s what they say. One thing is you should use a pain scale. Don’t just tell me their pain is hurting.
Give me a level, the only problem with the pain scale. How do we really measure what is the difference between a seven and a five? So what I believe, and it may be even a better tool. So take a look of what it talks about here, about functional measures, and you’ll notice a common theme, documentation of a patient’s level of function as an important aspect of patient care.
The documentation is required in order to establish medical necessity of ongoing acupuncture treatment. It says the patient specific functional scale of the PSF. Is a patient reported outcome that is easily and appropriate for acupuncturists to demonstrate the care. So keeping it simple, don’t think it has to be very hard, but keep simple things of a patient’s telling me not so much how much it hurts, but how pain affects function.
In fact, I’m going to give you a tool today that you’ll be able to take away from this presentation. So what this is all pointing to is that medical necessity comes down to data-driven. Tracking changes and restrictions of activities that they live, not just paying. Cause if pain was the only measurement, heck we might as well take pain medication, but pain medication, of course, all the other side effects.
And the fact that there’s no increase in function, it means it’s not quality care. So we want quality care that not only reduces pain, but increases function. And that’s frankly, what you do think of how many times all of you have had this miracle in your office. A patient comes to you. They’re basically.
And they’re saying I’ve been to a Cairo, I’ve been to medicine, I’ve tried this, that physical fit. They tried everything and they figured what the heck I’ll let acupuncture give it a shot. They come in and after a visitor too, they’re like, oh my God, I can’t believe it. Think of the. Of that.
I bet some of you became an acupuncturist because that happened to you. What we have to do is deliver that in a way that not just that the patient sees it, but that we’ve documented them, seeing it, think of it. Have you ever been to a medical doctor? And I don’t say this as a negative, but that’s not the way they treat.
If you ever went in and you left going, God, I feel so much better. My headache is gone. That’s not the way they treat. They prescribe the send out of their information. You have the power of someone can come in with a headache and literally leave. Was it before. That’s the powerful. That’s a value that patients want.
We have to make sure did we demonstrate it. So I want you to thinking along the lines of something we call Promus, this is the new term you’re used to outcome assessments, but this term promo stands for patient reported outcome measurement instruments. And you’re familiar with many of these Oswestry, the low back one neck general pain index.
I want to show you some examples to implement some easy ones to don’t make your life too complicated, because frankly, as much as I like this is the one for the Oswestry for local. That’s 10 questions. That’s a lot of information. Will your patients really adequately fill this out accurately? Every time you do it, to make sure you really have got a valid assessment.
And I’m going to say in many instances, no, if you’re going to use this one, I would make it part of the history or exam that you ask the questions because your patient may not remember what they said last time. And how many times have you had a patient tell you they feel better? But yet their pain scale, they note it was higher.
You’re going to go wait, that doesn’t match because they don’t remember. So this is good, but is it sometimes not as valid because patients just simply don’t fill it out accurately. So I’m going to recommend something simpler. This is called the general pain index. I particularly liked this one because it covers almost any condition.
I don’t care if they have headaches, abdominal pain or knee pain, because what this does is it focuses not on how much it hurts, but more about the function. So notice each question. Family and home responsibilities, recreation, social employment, and so on are focused on not how much it hurts, but your ability to function.
If you have good function, it’s a zero. If your function is reduced, it could be, completely it’s a 10. So the higher, the number of them when the patient scores this, the worse off they are. So we do this at the beginning. Maybe they score 30 points. After two weeks of care, you do this again. Now they dropped down 10 or 15 points.
It’s clear evidence. Objective. Of how the patient has changed, not about how I feel, but the function part of it. You correlate that of course, with other objective findings. How about this one? This is something new called the pain interference, and this is something the VA is really pushing and you’re going to notice, we’ll see them.
That’s pretty much the general pain index, except it’s just not as detailed notice. There’s only five ways to report this one, as opposed to the tenants. Where it’s interfere with day activities from a little bit too very much. It’s still good. I just don’t like it as much because it’s not as quantified, but this is when you could do weekly.
I prefer something with numbers, frankly, because it’s a little bit easier to score, but this is a good tool as well, because this is the evidence of the change. If someone’s losing weight, when you put them on a diet, how do you prove it to I’m on scale, then the next time you use these scales. So think of it when you’re going to make a request for services.
We have to have something we can provide to show that the patient’s gotten better. So I’ve taken this from the VA’s requirement for increasing or for requesting additional care. And it says what they’re looking for, a significant durable pain intensity. By functional improvement by clinically meaningful improvement on validated disease-specific outcome instruments.
Oh my goodness. Where have we heard of this? Do you see the consistency here? And of course, if there is any reduction of pain related meds as well, but it says here, objective measures demonstrating the extent of meaningful clinical improvement today. And the rationale for treatment requesting care is what they need.
Show me that the patient, Hey, they’ve improved 20% after two weeks of care and it’s been considered. Why wouldn’t we continue that care until they’ve reached a point of plateauing where there’s not any improvement, realize that so long as the patient’s improving, there’s a reason to continue care when the patient plateaus at a certain point, obviously that’s when we put them on a maintenance, stylish means not covered by insurance, but at least something where the patient can know the value of it.
And notice it also indicates including any barriers to recovery. So you want to think along the lines of, do I have information that someone reading it could go, oh yes, this is what. A statement of, I feel better. Isn’t that valid. So let’s take a look at a medical necessity when it comes to American specialty health.
This is the one that probably can be some of the strictest. What things do they rely on diagnosis? Of course, past history. Those things obviously creates the Verity, but comorbid factors, but notice what they look for, findings things that you can objectify range of motion, palpatory, tenderness, orthopedic testing, neurologic testing.
I’m not saying you have to do all of these already. But you have something that you have to have objective, even if you’re doing tongue and pulse. Tell me what’s better. Give me a way to show on paper. If you will, how the patient is better in a measured. So functional limitations is something they rely on as well.
In fact, if you’re used to the pre-treatment authorization forms and that includes Ash Evercore, Premera, they all refer to these. So I’m just going to say, make your life easy, begin to use the simpler outcome assessments. And I would suggest initial visit and probably every two weeks, but no greater than once a month, understanding that the whole goal is to reduce pain, but more so increased function.
So I’d like for all of you to think for a moment, how am I going to make this happen? We can be a good source for the American acupuncture council of course, is your malpractice carrier, but we also help you with these types of issues for any of you that have our outcome or our our AQI code.
We have all of these forms on there. Take a look, do this QR code. Certainly you can come to our site, take a look at our information. What I want to make sure is that, do you have the right tools and places to go? We’re always going to be a resource for you. I’m going to say to you, if you have any. Where are you going to go?
Don’t Google it. Come to the experts at the American Acupuncture Council. Thank you for everyone. I’ll see you. Next time. .
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hi everyone. This is Sam Collins, your coding and billing expert for acupuncture, not only the acupuncture profession, but of course the American Acupuncture Council and the Network as well. Welcome you to another edition. And today we’re going to discuss. How do you grow a practice? What are we doing? And what’s going on out there.
And I get this question quite a bit from teaching so many seminars over the years in dealing with so many acupuncturists, one of the common questions are, how do I grow? What do I do to get better? What do I do to get more people? And so I want to address that really from both ends of the patients, you’ll get, whether it’s going to be a cash practice and insurance practice.
Com combination of both. It’s going to be a matter of how do you attract the patients that you’re looking for. And let’s give you some ideas and some things to chew on and think about to see how your practice is going to change. Because one thing I will say is you always have to be willing to admit.
And to make changes. If you think of it, when you first started practice, you probably don’t treat this the same way you did when you first left school or five years ago or 10 years ago, if it’s been a long time and that’s because you learn and grow, it’s one of the reasons we have continued education.
And in fact, I would say, it’s why we call it a practice. And not a perfect, so let’s go to the slides. Let’s talk about what we want to do to grow our practice if you will. So here you go. We just look at how we change from that little bud to something that moves a little bit more. Let’s talk first on what do we consider success?
And this is something I think sometimes is going to be defined differently by different people. And where I have a concern is often too many people try to define what someone else should do, as opposed to just define on your own. So I would say define your own practice success for some of you. It could be, I need to make a million dollars for others.
I just want to help patients. And obviously I think everyone wants to do a little bit of both. I’m not sure I want a million dollar practice. That’s probably a million headaches, but think of how are you going to define what you’re doing? What does a successful. I would say it’s a combination of certainly there has to be a monetary success.
You have to stay open, but at the same token, the satisfaction, this is the part that I’m not sure patients always know what we do or how we do it and the results of care. And I want you to think of it in these terms. How often has you have someone that’s coming to your office? Not feeling good and literally left feeling better.
When does that ever happen? Outside of an acupuncture practice, frankly. Has anyone ever went to a medical doctor with a headache and left with it better? And I’m not saying that as a negative towards the medicine, but that’s not how they treat. So I want to think of what we have to define it, but then if we’re defining it, what are the barriers?
What are the things preventing us from really moving forward and doing a little bit more? How are we getting more people are not getting more people, where’s it going to come from? What things are we looking for? Is it a matter of changing styles and techniques to get better results? So start thinking of what are some of the barriers I’ve set up internally, meaning among yourself, but also among the patients.
I think for patients, you always have to think of how they value our service. And I think this is going to be the number one way to think of it is that people value a service. And when they value. They’ll get it. They’ll pay for it. If they don’t value it, they won’t. So we’ve got to set up that value and think of what is that barrier will barrier as often.
So we have to think of if I’m going to grow a practice and money’s the barrier, how do I change that? How do I make it work? So think along the lines of what is the model I have, like currently, what is your model? Have you really set forward a business plan. It’s something that you set for and say, here’s what I want to do this year.
And literally write down some ideas because until you write it down and then really follow through, it’s going to be too esoteric. So I think it starts with people in. So you’ve got to think of first off the barrier is people just knowing what we do, why we do. So I want to ask you, what does acupuncture do once you think of what you think it does, but I also want to think along the lines of what does the average person understand about acupuncture?
What is defined what’s out in the field that lets them know what we do, what message have we gotten and what message has the profession or others set up for us? I know a lot of what we have to deal with this kind of. Healthcare in the U S is very medical oriented, obviously. And it seems that people like to line up for pills and surgery, but when it comes to making changes in their life, having a better lifestyle to stay healthy, they want to be lied to, it’s okay. In other words, it’s interesting when people think of insurance, we often use the term health insurance, but I would ask you, is it really, is it actually health insurance, or is it sick? In other words, we have a model that we say health care, but is it really, I get there’s some preventative things.
We do cancer screenings and so on, but really is there anything to set up a person to be healthy? So that’s one way to think of there’s a portion of people that are understanding that no, I need to stay healthy and not get sick. So what role are we there and how do people know that they can even access with access that with us?
But I want you to think along these lines here, there’s an interesting meme. Someone had sent to me and I think it fits. How do you think people view acupuncture? Here’s one where it shows what your friends think. Think of, particularly for many of you who went later in life to become an acupuncturist, some of your friends are like, what.
And then of course your mom thinks you’re driving a big needle into someone. Of course that’s not the case. And then let’s face it. This Western medicine have a downside to acupuncture, to an extent. Yes, I will certainly say that’s not as bad as it was, but I’m not going to say there are proponent per se there, we’re not throwing money down the toilet, but that’s often what they’ll say.
What we think we’re doing is so much bigger than that, but let’s take it. There were two realities. What people still do take medications. Don’t do well. Face it, the VA has a problem with suicides and deaths because of the way that. But what do we really do think of this? A patient often feels when they come for acupuncture, but do people know that?
So what is our message? What information is out there? We’re, here’s two examples. The Mayo clinic and Cleveland clinic, this is something they have on their website about what acupuncture does. And though there’s some similarities there’s differences between the two, which you can see here, chemotherapy induced, nausea, dental, pain, fibromyalgia headaches, labor pain, low back pain, neck pain, osteoarthritis.
And so on, on that side. But notice here it says differently. And stroke cramps, sports injuries, cancer, and cancer treatment for side effects, face pain. I think of Justin Bieber recently had that issue. I hope he’s going to an acupuncturist, immune problems, infertility irritable bowel. So this is a pretty broad scope of things that acupuncture does, but yet, how does the average person know this?
Now? I just searched this at their website. So if you think of it, when someone’s searching for what acupuncture. This is going to be the first things that popped up. And I did that because I wanted to see what does come up. So we want to start to think of, if people are seeing this, how are we communicating the message or do we want to communicate a different message?
Here’s something interesting from the company, Kaiser Permanente, a big health insurer and the doctor all in one, it’s an HMO and this is from their head acupuncturist at the Kaiser. And it says, what does acupuncture treatment says in China? Acupuncture is used to treat. It’s not thought of as alternative medicine, which is very true for most people.
It’s a common part of their medical care in China. Acupuncture is often used as complimentary treatment for all types of health conditions. And that’s one of the things that through my work with Maryland and Ellen and others at WHS. The world is beginning to recognize that acupuncture is way more than just pain relief.
We know that acupuncture speeds recovery. I would suggest every person w having any care post-surgery should have acupuncture. However, again, are people aware of it and have they had a chance to try it. And I think this is going to be our issue. So when we talk about growing your practice, we have to attract people that know that what we can do can help.
By example, we leave it up to the other companies. I just showed you what comes up on the Mayo clinic. So if you typed in, what does acupuncture do? The number one is going to come from those areas, but you’ll notice this here companies like United health care use acupuncture as a medic. To advertise people to buy their product.
So do you think that they’re using acupuncture as a tool for people they are, which means there’s access? What if someone says what do you mean? I get acupuncture visits with zero copay. I think I want to go in now realize that this is a plan that I’m not going to say it pays a lot of money, but it pays it above a hundred dollars a visit.
So certainly something that might be viable for some, for others, they may say, Nope, I want to do all cash. What my point is. If a patient comes in with this and you are not available to it, they going to go and, or can you sell them an alternative? Look at this particular company for a Medicare advantage plan, literally they’re talking about acupuncture, but showing it.
So I’m seeing a lot more people now becoming a little bit more attuned to say, Hey, maybe I want to try it because we’re seeing it out there more. I want to start to change the narrative and attract people to what I do by example, here’s the company Evercore. Now, sir. 20 years ago, would insurance coverage was different, but Evercore, which manages a lot of plans, you’ll notice here, the things that talks about adjunct cancer care and mental health.
Now mental health is more than PTSD and anxiety, but even anorexia bulemia. Let’s face it a little bit of everything, including menopause. So we’ve got to start to realize that there’s a message out there. Are we directing that message? What is our message? What is your message? If you’re growing your practice, if someone’s going to find you, how are they finding.
Why are they going to come to you? What is the messages like if someone were to look you up on your website or your blog page or anything like that, what would they know? What if they drove by your office? Would they know anything about what you do and the why I should come? And I will tell you, we’ve got to set up that people have to have not so much a need, and I’m not saying there isn’t a need, but a want, and this is something that my mom taught me early on.
She said, people will buy what they want. And big for what they need. And this is part of the reason I think acupuncturists can do very well with cash. Partly because insurance is traditionally not covered as well. So therefore we’ve not relied on it. In fact, the American physical therapy association noted that if patients have a $30 copay, they won’t go into Acupac or go to a PT, or at least a third of them, they don’t find that same thing for Acura.
And I think because we set that message of someone wants the care. It doesn’t just feel like I need it. And we’ve not realized. So in other words, we have to set up and create a value. So if you’re going to grow, you have to grow by expanding some way either you are going to see more people or less people, more visits one way or the other, which means there’s some out of value set up.
So you’re going to think of, as someone drove by your office, What would be the message. Here’s a couple of examples of offices that put up things like, what did they treat? Think of how often someone might have something like fibromyalgia and they’ve never heard that acupuncture can help it. So why would they think you can help it?
What about Bell’s palsy or weight control? We have to set the narrative because think of when someone passes by, they see acupuncture, I don’t even think about it. I’m going to suggest we want to start creating that. Outside your office. What do you do? Do you do fertility? If so, let people know because why would someone come to you if you don’t, they don’t know what you do because you don’t tell them.
In addition to that, I want to think of, what about does your website say about you? Here’s an interesting, I just did a quick search to. Acupuncture and insurance coverage and acupuncture treatment. And this is one of the things that popped up. And I thought this was interesting. What types of health insurance covered?
I, this is actually someone’s website. I didn’t put their information at the top, but notice they’re indicating if someone says, Hey, I have this particular plan. I know what it can do. Aetna banner blue, cross blue shield plans that they take, if you’re going to, except some, I would certainly let people know.
Cause if someone has, But you don’t list it. Why would they come in now? Good news. Do you have to accept insurance? No. In fact, even have to bill insurance. No, that’s a courtesy. My suggestion is always to have a diversified practice. And what I mean by that is diversified in this way. I’m going to take people who can pay for my service, what I prefer, all cash.
You bet I would. But what about the people who have insurance? Would I turn them away now? Certainly if I have a plan that doesn’t pay very well, not too many. But plans that do, I certainly would want to be part of that or at least accept them. Keep in mind if there’s an insurance, you don’t want to build don’t bill.
When you do want to build, you would, but if you’re accepting any, does anyone know? Think of it. What if someone says, Hey, I have Aetna and they were looking for a provider. Would your name pop up? Remember if you don’t have a search engine that does it, it’s going to be a problem. Here’s one that as another website that I did, and those are the things that.
Bell’s palsy, difficult diseases, natural pregnancies, skin conditions, pediatric and geriatric care, migraine headaches, severe and chronic pain. What are they sending that message towards? Who are they trying to attract? Why are people will come into that office? What about veterans? If any of your treating the VA I would ask you, does anyone know that you treat it and in other words, think about it.
When someone sees you, what do they know about. The message we get and sometimes that message we’re letting someone else determine it. So I want you to think of a model situation. You are a business. So think of the show shark tank a little bit. If you were to take your business model onto the show shark tank with someone invest.
Now, I’m not saying in reality, but the idea is that a solid business model. So you’ve got to think of businesses. How do businesses change and grow or close by example, the company series. Was the biggest retailer in fact, had a complete catalog and shipped everything. What did Sears not do? They didn’t adapt.
I think of it. Amazon took their idea. What if someone at serious said, Hey, wait a minute. This company is, we’re going to go back to that. We already have a catalog. Why didn’t they do that? Because I felt there were too big. And so they wouldn’t integrate, they wouldn’t adapt. So what happened to Sears? But it’s interesting when you take other stores, take the store target.
I find that interesting from a business standpoint, if you go into target, you’ll notice when you first walk in there’s a little 99 cents store items in that place. They, they got three, four hours, not a lot, but what is that doing? It’s attracting the nine instance. ’cause people like that stuff.
Why not offer a little bit of it? So think of in your practice, do you offer a diversified way for people to come in there? Is it one way or the highway? I’ll give an example. I have a very good health insurance. I literally have no deductible. I pretty much have no copays. That sounds crazy, but let me have you understand something for that plan.
It costs me and again, you’re going to think. I’m kidding. Okay. About $3,000 a month just under that. So when I say I have no doubt. What does that really mean? Yeah, I don’t, but I’m paying $36,000 for no deductible. So the reality is it’s expensive. So does everyone have that type of policy? No. So if I walked in, I would certainly say, you’d go, yeah, I’m going to take your policy because it’s a really good one, but not everyone’s is, and that’s something you have to learn that there’s nothing wrong with cherry picking.
You can say, oh, I’ll accept this plan, but won’t accept that one. We do the same with any patient. So think about what is your diversification here? Have you seen modern acupuncture? That’s very. That’s an all cash. How do they make that work? Part of how they do it is they make their visits very inexpensive.
So you have to learn how to make volume work. Now, the difficulty is that we can’t have multiple fees for the same service. Now, if you were in a completely cash practice, you can set your fees anywhere you want. But as soon as you bill insurance, now we have to have a balance because you can’t appreciate the ability to insurance patient more than a cash patient, makes sense.
Same price. Now, keep in mind though, this model does work well. It’s a very popular one. Now, how does it work though? People don’t buy a single visit? You can, but it costs a hundred dollars. If you buy packages of visits, it changes to as little as 60 or maybe 40 or even $20 a visit. It’s just a matter of making sure we have done it right now.
I’m going to say to you, is there any reason you couldn’t offer that in your office? In other words, you’re like targeting you offer that cause are there going to be patients interested in it? I have a couple of practices that their whole practice is based on prepaid. Liberal. The in fact, they don’t do anything but prepays.
And she says that they sell about 25 to 30 every month. Her cheapest one is about 600, most expensive, about 5,000. No kidding. Now she will tell you she doesn’t sell that many of the 5,000, maybe one or two a month. Still not bad. The idea being though she set that up. Now the difficulty with that though, was this, when you have that type of practice, if the economy.
Is low. Does that start to dry up? So I’m going to suggest yes, but why do it? And I offer both, in other words, I will take some good insurance, but I’m not taking all of it. And I would prefer to do more cash, get people interested in health care. Remember insurance only covers so much. What about your true health care?
So you want to think along the lines of what about doing that, but here’s the part I want you to see? What does someone see? How is your office viewed? What do they know that you do? What do they know that your costs. How do you come across on a personal level? When people see you, do they see someone professional?
Do they see someone when they meet oh, this is the person I want to go to. This is a person that gave me some writing formation. What is the community around you think? How are you in the city or the community you’re in? How are you viewed? We set that narrative. What is your web presence? What if someone were to search acupuncture to treat whatever and your city, would your name pop up?
Here’s something I’ll guarantee you the American acupuncture council, the network, our education division. If you were to type in acupuncture seminars, guess who’s going to pop up first. We do. We do it by design. It’s not by happenstance. We make sure we put out a lot of information too, about how to run your practice.
And it’s not about all insurance. But that way, people know that you need continuing education in heck we teach a heck of a seminar that deals with just cash. But again, will you show up? What if someone says, man, I have migraines. Have you ever written anything up about it? Is there any information they might find?
Is there any blogs or any written video? Because you remember for a search engine is going to look for people who have put. If you’ve not put any information, you’re not going to come up. So start to think of where do we show up? Remember the old days of a yellow pages. No one does that anymore. So how did they find you?
What are we creating for referrals within our own patients? Is there any newsletters you send? Let’s go old school, send them out via email or even mailing. What do people know? I have an office that what they do is they work with. And every time they sold one of those welcome packets they’re included in there.
Cause I know I get some periodically in my neighborhood and it’s always a dentist or two chiropractor, a few medical doctors, but have you ever thought, Ooh, is that a way for you to go in? Hey, I’m looking for an acupuncturist and then think about what about groups that you might work with? Have you ever thought of any civic groups that might need someone to come do a lecture now?
I’m not saying that’s going to be as prominent now that’s probably coming back, but start to think of how am I adding. Have I worked with any sports teams and I’m talking not professional, but what about being the person for a high school team that helps deal with pain? I’ll give an example. The I coach high school kids.
And one of the things they know is if coach Collins is talking to him about treatment, I’m always wanting them to get acupuncture because I have found a person with acupuncture gets well faster, simple as that. And once they see it work, it becomes a thing. And quite frankly, I coach at the most prominent sports high school in the U S and everyone knows what’s going to happen when you’re one of my athletes.
My goal though is that, do people know that you do that? So where are your patients? There’s lots of patients. Everybody’s account. Technically even some insurance. So start to think of how am I getting my cash? Am I advertising? If you are all cash, how are you using that to your advantage? Is it on your site that your price is cheaper, it’s more affordable or is that the right?
We don’t want to go. We want to talk about the quality of care. Here’s one thing I’m always concerned with is cheaper. Always better. I don’t think so. I’ve never picked a doctor because it’s cheap. No. Now, I’m not saying there isn’t times that many of us do, but I want to think along those lines, but realize there are things you can do.
What about a prompt payment? What about a pre-pay and then of course all the different types of insurance. Now, what you’ll see here as well, there’s nine different ways of insurance. I will point out not all of these are good. And I think this is where people go wrong. You are going to have a practice that’s diverse and accept the things that are welcome to you.
And the ones that aren’t the medical doctor I go to, which is very rare. He doesn’t take PPO and HMO insurance. If you don’t have a plan like I do, he doesn’t accept you. You can pay. But if you’re going to use insurance, he doesn’t accept those lesser ones. Now his practice is busy cause he’s built that you’ve got to be able to stick with it.
Know what you’re looking for? What are the patients looking for? Cause here’s what it comes down to. If your practice is going to grow it’s about patients, it’s about how do we attract them? Start to think of what have I done to attract patients and then start tracking, do things and see, Hey, did that work?
Did it help? Did you create something where you tried to create a referral based within your own. Maybe something you let them know, Hey, have your patients come in or have your friend come in, we’ll give them a free consult. Things of that nature. Does it work? Does it not work? If you do a cash discount, you do a group on, does it work?
Here’s what I’ll say, deliver what you do best, which is to make people feel better and your good care. But we’ve got to make sure people will know that we do that. And are we setting that narrative? If you’re not looking to grow. And even grow a little, you’re going to shrink, which means you won’t be around.
Here’s one of my concerns and this sounds awful, but it’s true. Approximately half of the people who graduated from acupuncture school within five years, no longer practice. And I think that’s mostly from bad management of the business. And I think partly because this is something that’s the hard thing to deal with it and know it doesn’t work.
You can make anything work. If you stick with it, there are practices that do all cash and do very well. I’ll tell you what though, by a tee, they all have really good communication skills. They also generally are in higher than average areas of income and have built that in. But if your practice is about in that type of area, maybe a bit difficult, maybe you want to be a little bit diversified.
I said, deliver what you do best. This is what I want people to feel when they go to an acupuncturist, how do they feel after? And sometimes that’s going to be your best way. Do you have anything on your site that gives patient testimonials about, I can’t believe it. That’s usually going to be the best way to commute.
I help a lot of people, everyday acupuncture offices deal with problems from billing and coding, to collecting, dealing with cash and all those things. And some of the best ways I can communicate is just simply give examples of offices I’ve helped and how we’ve helped them. And that’s how you continue for the rest.
So I’m going to say, go out and start to think if you’re not thinking of growth, if you’re not implementing it. And there’s several ways to go. There’s not only one. We’re here to help you. The American acupuncture council is always going to be your resource. We have a network service where I become part of your office.
Call me, email me. We deal with everything on a day-to-day basis, no limits. And it’s not about insurance. It’s about everything can include insurance. We are a resource go to our. Take a look, we have a lot of free things out there along obviously with these types of programs. But what I will say to all of you is think in your own practice, what am I doing to make my practice better, to make my self better?
I think we’re always doing that, but how do we communicate it? So I’m going to say thanks for the time everyone in next week is going to be Chen Yen. So again, go out, be successful. Hope to see you at a future seminar. Take care, everybody.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hi everyone. This is Sam Collins, your coding and billing expert for acupuncture, the American Acupuncture Council. And of course, just the profession. Welcome to another episode to always help you get your practice uplifted, make sure you’re getting paid for what you do, because that’s what I do. We try to make sure that you get your claims paid, can get paid for your services.
One of the questions that I get quite a bit, is, can I get reimbursed for codes beyond pain? Now, of course, I’ve been teaching acupuncture seminars now for some 26 years, and so we often get people saying what’s now what was then truthfully, if you went back to a seminar I did in the nineties or early two thousands, there were very little reimbursement beyond simply pain that has changed quite a bit.
We still have to understand, that it’s not quite as open as we would like, but much more so it’s good to know what will get paid and can I get paid beyond pain? So let’s go to the slides. Let’s take a look at what’s occurring here. What’s going on with insurance and reimbursements for acupuncture now as always, here’s my email.
Here’s our website as well, but let’s focus in on acupuncture covering. When insurance has to pay, what do they pay for? And I think this is often where people get off track. The assumption is, oh, they pay for everything. Not quite. And there can be nuances that some will pay for more than others. In fact, there’s one that honestly will pay for everything, which I’ll give you a demonstration of.
One of the things we have to think of is how do people foresee or what do they see when they think of acupuncture? Think of it. Ask your friends, ask an acquaintance. What do you think? I. What do we treat in acupuncture? And I think you’ll invariably give you it’s pain and have an ignorance toward, and it’s part of our.
I think to make sure they understand we do more than that. So by example, I’m showing two offices this year that have some signs up near their office or in their office that talks about the things they treat. Notice this one on the left talks about fatigue, stress, anxiety, depression. And in fact, they don’t get down to anything towards pain until the very end, because how many times people have these types of conditions and think, oh, they don’t associate it that way.
Is there coverage for it? I think partly is making sure people know that acupuncture can treat. And more importantly, or maybe not more importantly, but just as a. Can I get my insurance to pay for it. Look at this other one, they talk about pain first, but then brings in things like anxiety, depression, Bell’s palsy.
Heck I think a Justin Bieber, if you’re familiar with his condition probably should be getting some help from an acupuncturist. So it’s really understanding what do plans cover. Can it be more than just pain? Cause that’s what. Obviously, many of you are aware of the American specialty health model, which I will call the musculoskeletal model or an often I’ll think of it as the physical therapy chiropractic model in that what they cover things like headaches, hip, or knee pain associated with arthritis or extremity pain with arthritis or other mechanical irritation, meaning strains and sprains, or just pain syndromes of the joints and soft tissues back and neck pain.
So you can see here for the most. It’s mostly just pain. A little bit to Nazi with pregnancy, but notice nothing here about abdominal pain or how about anxiety, depression, or anything else beyond that generally? No. Now the good news is pain is often what you’re going to have with any condition, how it manifests itself, but this can be fairly limiting and for many plans can be.
So by example, is there something I can do more than. And not all carriers are the same. There are going to be differences between each of these. And I’m going to demonstrate some of the differences that you’ll see among these to start to give you an idea of it. I’m going to recommend this is why you want to get more continued education with programs like ours, to really get the full breadth of what can be covered and the nuances from state to state region.
So by example, here’s the newest Aetna protocol. And as you’re probably aware all Aetna policies that are now from their commercial line have to cover acupuncture, but you’ll notice here it’s still pretty limited. It’s limited because it says it covers neck pain and headaches, low back pain, nausea, arthritis, chemotherapy-induced nausea and TMJ disorders.
That’s good. This is a pretty nice. Only pain, but it is when you look at these other than the arthritis, so this one could be pretty limited. The good news is Aetna will tell you what codes they cover. So here’s their list, everything from migraines, all the way down to postoperative pain to the teeth.
So pretty limited. Now the thing that this list says though, is that it’s not all inclusive. So the difficulty is you get a list like this and you think, okay, great. This is what I know they’re going to cover. You build these, they pay it, but are there other things that I can do. That they may pay. What we have found is generally other joint pain, but I’ve had a few offices believe it or not with.
That have been covered for anxiety, depression, with the code M 48.1, certainly something you could venture into and just say, if I’m treating that, is it a possibility? Many of them are working concurrently with some type of medical provider treating it as well, but you can dip your toe. What I can say is this one though is pretty straightforward.
This is what they’re doing. Without question, as you can see. That’s pretty much pain Sam. What about Cigna now? Cigna, this is their newest coverage and they cover a lot of things. You’ll notice here in the bullets that says tension types, headaches, migraines, musculoskeletal joint, nausea, post-surgical pain and chemotherapy induced nausea.
So you’ll notice it again is still along the pain. Now this list from Cigna though is vast. If you tell me any joint with a stranger. Or any type of pain to a joint, they’re going to cover it. Myalgia, fibromyalgia. You bet pretty ubiquitous, but again, is it beyond pain? Not really. Not until you get into companies like this particular one.
This is the company Evercore. And to give you the background, Evercore is behind the scenes for most of the products that are sold under Anthem, meaning blue cross blue shield. United health care. And of course, Optum and you’ll notice right off the bat, what they cover are pretty much pain codes. You’ll see.
Okay. The neck, the back musculoskeletal, cervical cranial lumbal sacral pain. But then you’ll notice that the very end of the list, it says internal medical conditions, and this is something that’s remarkable and has been around now for about three years. Take a look at what things. Adjunct cancer care.
Now I want to be careful. They’re not saying they cover to treat cancer, but they’re paying you to treat the symptoms associated, the nausea, the vomiting, the other conditions associated with it. Notice also the mental health conditions. These are things like PTSD. Believe it or not anorexia bulemia but also depression, anxiety.
I would suggest, always be working with probably concurrently, but at the same token, this is something they’re not saying no to notice allergic rhinitis, adjunct post-stroke dry eye syndrome, constipation prostititus pain, asthma irritable bowel. Of course the vomiting you’ll stupid. Look at the very last one medical.
And this particular one, they’re not covering menopause just to say what are we treating you? Don’t you’re actually treating insomnia. And hot flashes. So there’s really been a great growth here. Now I’m going to recommend, again, probably to dig in a little bit more. This is what we do, and that are more advanced or navigating the insurance seminars.
But you can see here while this is a little beyond, I particularly really hope some of the offices that when I first taught seminars, always taught to say, Hey, let’s talk about the code you get paid for. And they said, we didn’t do an internal medicine. I said we didn’t because it’s not paid. Now you can see here.
This is beginning to get paid. Now this company again, I did Anthem’s Optum’s are going to be more or less. In addition. What about another company like health partners? I know a lot of you in the Midwest area will see this one and they do have a pretty good amount of coverage for all the musculoskeletal things as you’ll see here.
But it goes beyond that. Look at section V here, PMs or menstrual disorders. In fact, they give a list of codes and you’ll notice here things like interstitial cystitis, Macedonia, menstrual disorders, vomiting, but take a look at the last. Weakness fatigue, malaise. There’s a lot of change that’s occurring that there’s going to be more so it begins, start asking, will this plan cover and don’t be afraid to ask, does it cover fatigue?
Does it cover abdominal pain? Will it cover prostititus pain, things of that nature to know, because not often as much as I’m showing you this list, does every insurance company produce a little. Not always. So we want dig a little bit further to say what’s covered and I would suggest start keeping a list.
That’s one of the things we emphasize in our program to know the codes that are covered or not covered that way. You have the best idea of making sure you get the best benefit. One thing we want to be clear with the patient, what’s going to be covered. Don’t be fooled. Don’t let your patient before. If you’re not sure something is covered, don’t be afraid to say we will bill your insurance.
And we hope they cover, but we’re never going to guarantee that’s the downside. People want to make people or patients believe everything’s going to be covered. You’re going to give, we’re going to bill your insurance confidently with the condition you have. Will your insurance absolutely cover. We can’t guarantee it until once we build now, here’s the beauty of this start collecting this data.
Does this insurance pay this particular diagnosis? Keep in mind. Most of you don’t use a lot of diagnosis and that’s okay because you see a lot of the same things, but begin to learn which ones are or are not covered. Notice this one here. If someone just comes in and says, I feel tired, health partners is going to cover it, but take a look.
This is one of my latest VA. For the VA take a look at this. This is just this may and notice what it is. Provisional diagnosis, tobacco use to help console the patient there. Now the VA is authorizing for some people to go, let’s try acupuncture to help with this addiction. Notice it says to assist with smoking cessation.
So have we changed? Is there more access to what you do? Yeah, because it’s beginning to be recognized. It’s one of the reasons we’re moving towards ICD 11 is to make sure that we can better account for all the things that acupuncture can do. My hope is we move to something like this. One, take a look for any of you that are in Massachusetts.
You have the Mecca of coverage, blue cross blue shield of Massachusetts. Now covers is in way that most aren’t even aware of. I want to see every state do this. Acupuncture benefits for 12 visits per year, for any reason. So this particular plan is saying, I don’t care what you have. We’re going to cover you for 12 visits.
In other words, an acupuncturist can be an acupuncturist, treat what you’re seeing, not to try to fit into some other guidelines. Notice here, all the things they’re talking about, dental pain, addictions, headaches, menstrual tennis, elbow, fibromyalgia. Now some of that is painted up, but notice digestive, emotional ear, nose, and throat.
Gynecological issues, literally anything. My hope is that we continue to move forward this way, because part of the best way for acupuncturists to get coverage is to collect data among what we treat. So imagine someone with let’s look neurological that has Parkinson’s disease, and we start to collect data that wow, people who have Parkinson’s that get acupuncture have resulted better from.
Do you think that might be something that will be more useful for the patient, but also for the insurance, remember acupuncture is always going to be the more economical choice. And so the movement forward is acupuncture. Can’t be hidden. It works and it works with. So as a consequence, better coverage. So I want to start to say to you, get out and look nowhere you can go.
That’s why we offer this service called the network, get an expert, which means me on your staff. Just hold your phone up to that. QR code will bring you right to the site so you can dig into this. Our Accu code has this list as well. We want to make sure you have the best information. Or no one it’s not going to be paid.
The American acupuncture council is your ally and your resource. Our group is the network. You can go to our site, take a look. Obviously many of you are insured with us as well, but at the same token, we want to be a resource that you can be helped to make sure that your practice continues to thrive and grow.
And that’s going to be about access to your. So I’m going to say to all of you, thanks for that time. Next week house will be Jeffrey Grossman, as always, I’ll say to you, it’s good to be important, more important to be good, be that person to your patient, make sure they can get access to care. The number one problem with acupuncture is people not understanding what you do and gaining access and gain their trust.
Let them try it. They’re going to get better. See you next time.
Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Hi everyone. This is Sam Collins, your coding and billing expert for acupuncture and the American Acupuncture Council Network. With our other episode on always looking to continue to grow your practice, to give yourself more opportunity, to see people and help people. And as always, I’m going to give you tips on coding and billing and really practice management.
This is a great time to be an acupuncturist, but how do we make sure we’re getting from gaining full advantage to get access to patients and the services we provide? So what I’d like to do with you today is to talk about coding and billing specifically for cupping. This is one that I get this question a lot is that seminar producer, as well as doing our network services, where people call them with questions.
One of the questions I get is, Hey Sam, how do I code for cupping? Can I get paid? What is the proper code? Let’s really get into that. So let’s go to the slides. Let’s take a look. What’s going on with. And how do we do it? What’s the coding and billing. Please note, there is our website. This is the network, not the insurance company, ACM phone network.
Remember we always have updates and news for you there. So what are we looking for? What do we need to do? What is. A cupping as well. Let’s define that cupping as a therapy at ancient form of therapy, where a therapist puts special cups on your skin or a patient skin to create suction.
That suction is to help with circulation, for pain, inflammation, blood flow, and so forth. And of course has become very popular. You’re seeing it all over. Let’s talk about, we know what it’s good for it. How do we use it? But can we get paid for it? Let’s talk about cutting more to define it more clearly.
What I’ve been able to research is that there’s about 10 different types of cupping, and I’m sure some of you might say, oh no, I think there’s five. This is just what I was able to research. And it shows you can have things that they call weaker, like cupping medium or. Moving cupping. I see that commonly needle cupping using moxa or needles with it empty or flash cupping, full bleeding, cupping.
You got to remember that. Is it within your scope for your state, but I’ve seen it used with herbs water and realize the cups can be made of several substances. I generally see some type of glass. I seen some very heavy plastic metals I’ve even heard. I’ve never seen it. I’ve even heard of bamboo.
And that kind of makes sense. What we want to focus on. How do we bill for it? Is there a CPT code that we can use that says it? The first thing we have to remember is whenever you select a code, and this is something that you must always do, you must select a code that accurately describes the service.
Not has to accurately do not be creative. Don’t select a code because it’s like it, like my example, if you were to use. Would you be able to code that as acupuncture? Just because you put seeds on a point, doesn’t make it acupuncture because it’s not needle. So it can’t be it’s gotta be all the way.
So don’t be creative with what you describe, do not select the code that climate is close. Always has to be exact. And within that. If there’s no code for it, there is a code, always. There’s a code called the unlisted code and it can be a modality or a procedure. So whenever you have any service and we’re talking cupping today that doesn’t have a code, that’s going to be the more likely code to use, but let’s take a look at is their way of coding.
It’s I’m going to show you something. I deal with a lot, which is dealing with audits. Many of you are insured with American acupuncture council. And remember if you’re audited who’s there. Remember, if you have American acupuncture council of malpractice, they’re going to help you with audits depending on your policy, anywhere from 30,000 to $50,000 a defense.
And this was one of the cases we had here was an office that had issues with coding. And you’ll take a look. I highlighted in blue. So here it says on 52 claim lines, manual therapy was identified as. In the medical records and reporting of the code 9 71, 4 0 is not appropriate using for the Madame for the modality to indicate as cupping.
So I want to make clear, some people will say Sam, I’m putting the cups on manually and I’m moving them around. So it makes it manual therapy. Nope. That would not make it manual therapy. It’s. And though you’re doing it manually, it doesn’t make it manual therapy. So again, be very careful and you hear a lot of people say, oh, sure.
When I use a cup, Nope, that would not be correct. And I want to make sure you can see this. This is directly from. And again, very clear that it’s not to be used for it. So is there a code for cupping? So if you start thinking of all the codes, infrared heat. Okay. Hot packs, electric stem.
You’ll notice there is no code for cupping. So we want to talk about how to do it. And frankly, let’s be clear. Is it really even a covered service? And I think that’s what I want to focus more on. How do you get. And to get paid for it by insurance. That’s what we have to have a code, but is it a covered service?
Take a look here. This is the VA and I’m sure you’re all familiar with VA claims. The VA is one insurance that will indeed pay for cupping 100%. You’ll notice here and I highlighted it where they indicate the services that can be provided along with your acupuncture. And clearly. Cupping, along with other things, but cupping is there.
So a lot of people look at the codes that are allowed under the VA. And I’ll give you the list here. Here’s the codes that the VA pays for an acupuncturist. Notice it was updated for this year. And you’ll notice that code. I put the blue arrows it’s 9, 7 0 1 6. Now I would say in theory, I think the VA is saying you could use that code.
I don’t think it’s quite correct, but let’s talk about. Should you use it? 9, 7 0 1 6 indicates something that’s called a Vasos nomadic device. And the indication for it is to reduction of a deem after acute injury lymphedema and the use of a pop. So I want to highlight you see this little, long kind of blood pressure cuff goes over the area.
That’s what a visa nomadic devices. It’s a large pressure device that goes over an extremity or part of the body that gets pumped. To prevent a DEMA post-surgical maybe prevent blood clots. It might have vibration to promote circulation and deal with lymphedema. Now I’ve had some people argue that well, could a cup be listed under that?
I would say I can see the argument, but I think this goes against the rule. It has to either fit it or not. I don’t think this would fit it. So I don’t think this is the best choice. And I also don’t think it’s the best choice, because if you use it, I will say the VA will pay it. But the VA Medicare rate is 12 to 1400.
It has a relative value of 0.35, which means it’s about 25% of the value of acupuncture. So again, not a very expensive code, 12 bucks now that’s better than zero, but is that potentially the best code? So remember an application modality, one area Vaser pneumatic says devices that provide external pumping forces to soft tissues to the lower and upper extremities.
And I would say trunk as well. So you would say with cupping, could it fit that definition? I could see you dovetailing it, but I still will stay. It is not the best. Cupping is very popular. You’re seeing it amongst sports and athletes and my goodness, the rock has even had it. And I love what he does because he has moons of followers that if he’s getting cut, the more people are likely to try.
Do I see even the person’s left, had a lot of cups place it’s really popular. It really has efficacy. I’m seeing a lot of additional practitioners from chiropractors to physical therapists that are doing it. So how do we. I mentioned the visa nomadic device. And I said visa, nomadic. I think you can argue it for the VA.
I would never use it outside the VA, but for the VA you could. But I think from a monetary point of view, you’re losing money because it doesn’t pay as well. Using 9 7 0 1 6 will literally get you paid less than 50% of what you would be paid. Otherwise when you use what’s called the unlisted modality code.
Now I want to go back for a second and I’ll go back here and show you. You’ll notice those codes are like, 9 7 0 3 9 and 9 7 1 1 3 9. So you can see they’re all on the list for the VA. In addition tonight 7 0 1 6, but those codes do not have a Medicare value, which means when there’s no value purported by Medicare, they pay at usual and customers.
So what I’m saying to you is simply. If you’re billing, even the VA for cupping, what is the best code to use? It’s going to be the enlist of modality. Whether you want to say it’s unattended or attended. Now here’s the difference. 9 7 0 3 9 says unlisted, modality and modality in this way means something.
You apply to a patient, but you don’t have to be there. Like I know when I’ve had cupping, they placed the. And they leave them there for a bit. I would say that’s an unattended, probably appropriate code, but I’ve also had cupping where the provider is constantly in attendance adjusting and moving them a bit.
That’s going to be more of a procedure or hands-on. So the more hands-on and that you’re spending time with the patient 9 7 1 3 9 would be the better choice if it’s completely unattended 9 7 0 3 9. The difference, just to give an example, if you bill 9 7 0 1 6. They’ll pay a 12 to $14 bill 9 7 1 3 9. I’m going to say payment is going to be between 30 and 45, depending on your area.
So would you rather get paid 10 or 30 or 40? I would opt with the higher one. So how do we code this though, to make sure they know what’s coming says it says unlisted procedure, which means it could be for anything. So you have to indicate cupping on the 15th. Actually, it’s not hard. You’ve all seen a 1500 for here’s an example.
Notice on this line item, it says 9 7 1 3 9. And then in the pink shaded section, right above it, you simply indicate that tells the insurance it’s cupping. Oh, by the way, what if you’re doing moxibustion how would you do that? Actually the same way you would just indicate moxibustion whether it’s fully active.
Or one that it’s unattended. My point here is that coding for cupping, the best code for you would be the unlisted code and indicated this cupping, the VA will cover it. They will pay for cupping. It’s part of the authorization. They will pay it under 9 7, 0 1 6, but at a third of the price. So I think it’s better to use this one.
Now, what about regular? Do regular plans generally cover cupping. The unfortunate answer is no, I’m not finding any type of consistent payment here and there I’ve seen it, but not enough for me to really say yes, it’s covering out. The more likely places to be covered would be personal injury more than likely.
But outside of that, if you go to, gosh, the Cigna, Aetna, the blues general, they’re going to come back and say, it’s experimental investigation, which doesn’t it. From your standpoint, it’s not effective, but you know how insurance companies are without a double-blind study. We’re not going to cover, explain to the patient.
This cupping services is going to be integral to you getting better. We’re going to apply it. This is why, and what we’re doing. And here is the cost. If you show the value and the patient sees the value, they will pay for it and it will be covered. So don’t be afraid to pass it on because if you’re not willing to pass it onto the patient, why bill and insurance, if you’re going to give it away, So I would say, yes, I don’t want to bill for it.
It takes time. It takes effort and it is effective. Quite frankly, I’ve seen some really good responses with muscle injuries that I’ve never seen with other types of modalities. Now we’ll hacky puncture too, but that cupping is really been something I’ve noticed because of the amount of use I’ve seen has really made things work better for patients.
So make it available. Billing wise, what’s the best. Unlisted therapeutic procedure or modality, identify it as cupping and then simply put your price. And when we’re talking just simply price, you’re far better to bill cupping under the unlisted code to the VA. Cause it’s a little bit worth three times the money.
So keep it simple. You know how everybody makes insurance billing hard. You just have to understand the parameters. And that’s what our program with you is to do and realize I do articles and acupuncture today, and this one date back to 2010 and actually talks about it and why I wanted to bring it up today.
That this question though, a lot recently, and it’s because it’s become popular because of the VA. Here’s the thing. You can have me as your. Don’t be afraid to reach out to the network service, because from that I become part of your team where you can call, email me, fax me. However you want to get ahold of me to help you with coding and billing, and frankly get paid my goal to make you better.
I’m your doctor of billing to make your office work better. So go to our side, take a look. I would suggest take a moment to go to our Facebook page AAC. Give us a like there and we always update and put news out. We’re always going to be a resource. The American acupuncture council of course, is your malpractice resource, but will your billing and coding and business to resources as there’s our site, there’s our phone number.
Please reach out to us. Don’t be afraid. My email was at the front end as well. What I’ll say to you all is thank you for the time and next episode, we’re going to have Poney Chiang and again, always go out and be successful. But remember, the success is more about being. Which means being good to your patients, be that person.
And I’ll see you next time. Everyone take care. So what I’d like to do with you today is to talk about coding and billing specifically for cupping. This is one that I get this question a lot is that seminar producer, as well as doing our network services, where people call them with questions.
One of the questions I get is, Hey Sam, how do I code for cupping? Can I get paid? What is the proper code? Let’s really get into that.
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