But let’s talk about today’s program. Let’s talk about when you see a policy that says they get 25 visits.
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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors. Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.
Greetings, friends and colleagues. This is Sam Collins, your coding and billing expert for Acupuncture, the American Acupuncture Council, the American Acupuncture Council Network. But more importantly to you, your success is ours. We’re always here to try to make sure that you have all the best available information to make your practice thrive.
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I want you to be the best possible provider and focus on that. Allow us the chance, the Council, to be that support service for you, where we’re there to help you with all the nuances. That’s what network members get from us. But let’s talk about today’s program. Let’s talk about when you see a policy that says they get 25 visits.
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What does that really mean? Or when it says we have 40, 80, or whatever, what about some plans that it’s actually unlimited? Does it really mean that? So let’s go to the slides. Let’s talk about this when we get policies that tell us the amount of visits that someone has. What does it really mean when a policy allows 25 visits?
Does it mean they get 25 automatically? That no matter what, I hope all of you are going, well, no, that’s probably not true. What we have to have every time is it has to be medically necessary. It’s not going to be just an automatic. It’s going to be, should it come up as something that’s necessary? In other words, if a person says, I feel fine, I feel perfect, but I want to get my 25 visits.
Will the insurance allow that? And that’s where we have some difficulty because when patients have policies like these, they have the false pretense that, Oh good, that means I can come two times per month this whole year and the rest of my life. Now, as much as I would love that to be true, that isn’t always medically necessary.
So we do have to keep in mind that we need to learn to navigate and achieve the optimum utilization, make sure patients are aware. Now realize, many people have conditions. Pain and otherwise. That could require some acupuncture services that will max out those visits and could be that way, but we have to make sure, do we have it medically necessary?
Is it automatic? Does it mean they get to use it at their discretion, two per month? But what about maintenance? Will that be covered? Well, first we have to think of what is medically necessary because in order to have 25 visits, you’re always going to say they’re looking for medical necessity, something that is necessary for the patient.
And that must be delivered with defined, reasonable, and evidence based goals. Now, realize As an acupuncturist, there’s many things you can treat beyond just simple what I call the physical therapy chiropractic side, which is musculoskeletal and pain. It can go beyond that, but we still have to have evidence of the changes.
It must be based on the patient’s presentation of their diagnosis. Make sure it’s a covered diagnosis. That’s probably going to be number one. For a patient to be covered for acupuncture, you have to find out what are the covered diagnosis. By example, Aetna and Cigna have very similar covered diagnosis, but there are many more with Cigna than with Aetna.
But what about Blue Cross Blue Shield? So it’s sometimes learning that nuance. This is what we do for you at Seminars, of course. So make sure we have the diagnosis, but then also, what is the severity? What are the clinical findings that demonstrate the need for care? It says, continuation of treatment is contingent upon progression towards defined treatment goals evidenced by specific significant objective functional improvements.
Notice it says here, outcome assessment scales, range of motion. The good news is, pain, which is the number one thing acupuncturists treat, is always going to cause some dysfunction of some type. Their function is going to be less based upon their pain. So talk about when a patient says they’re having pain, even if it’s headaches, what is this headache causing you to have problems with?
Oh my goodness, I couldn’t work. I can’t work more than 30 minutes at a time. We’re had to take a day off. All these things demonstrating some type of evidence of a functional change. I think acupuncture works very well here. Think of how many types of doctors you can see, but how many can you treat with that when you leave the visit, You literally feel better.
I mean, if you go to a medical doctor with a headache, and I’m not saying this is a negative, what is a medical doctor going to do? Evaluate you and make sure it’s not nothing more severe, but then otherwise give you a script for pain medication. They call it in by the time you can get the prescription filled, hours later, maybe the next day, then you take it by then.
Maybe the headache was gone on its own or it can help. Someone comes to you with a headache. How many of you have witnessed what I call the miracle of acupuncture? that they leave going, Oh my God, I cannot believe that worked. I’m without a headache and I came in with one. That happens all the time. So we want to demonstrate that the patient has changes.
So always rely on how you document as demonstrating the number of visits. Cause 25 visits are certainly reasonable. If you can show they have a headache after a certain number of visits or time, the headache is gone or reduced. Now, can that headache return? Absolutely. So it’s not a never ending. It says certain conditions require to be co managed by a medical provider.
If you’re dealing with, some plans cover addictions, strokes. Cancer related. Well, those you’d want to be working with them. By the way, I took this directly from Cygnus coverage and it says, medically necessary services including monitoring outcomes with progress and change in treatment, with a withdrawal of treatment if the patient is no longer improving.
I mean, let’s face it, how many patients are going to continue to come to you if you’re not helping? This is the hard part because patients start to understand the value. and necessity of care. Our job is when do we demonstrate that that care is no longer medically necessary from an insurance standpoint.
I think so long as we can demonstrate there’s ebbs and flows and we’re showing improvement or can be supportive, I think we’re going to be on the right track. Just be careful. Maintenance or non covered means it’s intended to improve or maintain general physical condition. I don’t disagree with that. I think certainly healthcare should be part of that, but that’s not what our insurance is for, is it?
Insurance says Sickness or disease. So it’s not about keeping you healthy. I wish we would no longer call it health insurance. We should call it sick insurance. It says maintenance acupuncture services when significant therapeutic improvement is not expected. So it’s maintenance when it’s not expected.
Now that doesn’t mean it has to improve every time. So when someone says there’s 25 visits during that 25 visits, if we’re noticing a continuance of improvement medically necessary, the difference is, How do we demonstrate it? Are you using outcomes to do that? Are you giving me the true objective changes?
Don’t tell me or rely on the patient feels a little better. That’s certainly not going to be adequate. That’s part of it, but they feel better. How? What functional change? What objective change do we have? It says services that do not require the skills of a qualified provider, such as acupuncture, are limited to that can be practiced independently and self administered.
So in other words, if you’re just saying we’re coming in and just doing exercises. only. They’re going to say, well, why couldn’t they continue that at home? So you always want to show that it requires a skill, meaning they’re getting true acupuncture services. Home exercise services can be formed safely and independently.
It can’t be just that. Now, should exercise be part of the care plan? You bet. But I want you to keep in mind, when I go to an acupuncturist, you know what I want? Acupuncture. Chances are we’ve tried exercise. Now that doesn’t mean you’re not going to give me some better ones. And I’ll say doing Qigong type exercises, if you will, or physical therapy type, or just gym type are all helpful.
and could be part of it, but the thing that separates you is going to be the acupuncture. So keep in mind, there is something though that insurances will cover, particularly on some of these visits, what they call supportive care. And it says supportive care can be referred to as ongoing or long term treatment or care, and it may be necessary as treatment for individuals who have reached maximum benefit.
In other words, they’ve reached maximum benefit, but you notice right after you withdraw care, They begin to have a significant drop off. Now, what we want to do, make sure we’re showing, because of that drop off, they’ve been doing home exercise. They’re doing things to help prevent it, but it doesn’t do it.
So, you want to demonstrate that the patient can get ongoing improvement. with the care. When it falls off, we get them back treating again. So keep in mind what they don’t cover though is a true maintenance. Supportive is different from maintenance. Supportive is in the absence of care, it significantly drops off.
Demonstrate that objectively and subjectively. If we’re just saying it stays the same and we don’t want it to get worse, that’s a difference. That’s where this comes in. The member’s symptoms are neither regressing or improving, is considered not medically necessary. If no clinical benefits can be appreciated after four weeks of acupuncture, then why?
Now, notice what it says here. They’re initially giving everyone probably four weeks. Now, four weeks for you could be one time a week. For another person, it could be two times a week. So, keep in mind, it’s not just number of visits, but over a time period. There are some service providers who might do one visit a week.
What I want you thinking of is, if I give care, Can I show improvement? No matter how many number of visits they’ll have, they’ll allow it. I have an office, and this is not a joke, they’ve treated someone probably the last, and I’m not going to over exaggerate it, for sure the last two years, I can say for sure, and they’ve treated this person 40 plus times every single year.
Now, grant you, they have a very significant chronic condition, arthritic changes, and so forth, but they don’t treat 40 continuously. They’ll treat usually 10 or 15 per an episode. They may not see them for weeks, maybe a month, and then treat another 10 or 15. And that same thing has gone on. What they haven’t done is just treat them every other week.
Now, some people might say, maybe that’s better. Well, unfortunately, that’s not how insurance works. So we want to make sure that we can demonstrate always meaningful improvement in symptoms and objective changes. And here’s a good example of a plan like this. This is the Costco plan under it. And I’ll just have you go to the first part here.
It says changes in coverage for chiropractic services. You’re thinking, what? Bear with me and let’s read on. Currently, chiropractic services are covered as an alternative care benefit. You pay a co pay for each covered chiropractic visit, and you’re limited to a combined total of 20 alternative care notice.
Acupuncture, chiropractic, homeopath, and naturopath. Costco is very generous. So what is that telling us? Do we get 20 visits per year? for acupuncture combined with others. But notice what began this year, January 21st, they’re allowing a little bit more for chiropractic, but it’s all based on medical necessity.
They’ll allow up to 90 visits per year. So what I want to highlight is visits, if they give you 90, 20, you still have to demonstrate the patient can get better as a result of the care. That doesn’t mean we’re curing, but maybe we’re getting to a point where they remain functional. And when that dysfunction drops, We continue treating.
Be careful. I think we’re the ones that have to explain to a patient. 25 visits doesn’t mean automatic visits. 25 visits still comes back to medical necessity. So we’ve got to give our patients a financial agreement. I hope all of you are doing something like this. It’s part of the no surprise, regardless of what a patient thinks is covered.
We want to put this out there. Many insurance policies do cover acupuncture care, but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. In other words, we’re going to do the best job we can to get your plan to cover.
We’re not promising anything. What we’re promising is good care and that ultimately you will be personally responsible for the payment of your deductible as well as any unpaid balances. We go further to say if you have insurance, we’ll bill as a courtesy. Of course we will, but payment for your deductibles if it has not been met as your responsibility.
Your copay is due as services are rendered. What we want to do is give patients good quality care. And here’s something to keep in mind. Your practice as a cash practitioner is important, but it’s even the same when it comes to insurance. Insurance pays part of it. It’s just easier for someone to come in when they have insurance that pays part of it.
I want to access that, but I don’t want to give a false sense of security. Think of it this way. When someone really needs care, they pay for it. There’s a value. We want to continue to have that value, whether there’s insurance or not, whether it’s unlimited visits, that the patient understands it. Keep in mind.
Acupuncture care works really, really well. That’s the medical necessity. But does your documentation present that? This is one of the common problems I see when I have offices I work with in dealing with when they get denials or non payments. How do we fix that? Well, demonstrate the patient made, the treatment made the patient better.
I would implore all of you, acupuncture works really well, but if you look objectively in your notes, Can you see that in an evidenced way? I’m going to recommend that you always use an outcome assessment on every single patient. Even if it’s cash, by the way. Get an outcome assessment. It demonstrates objectively how the patient is changing.
The two that I like the best are the general pain index. The other is the pain interference, the short form. The latter is the one the VA is emphasizing. If you’ve attended a seminar with me, you’ve received them. If you’re a network member, But start using things that show acupuncture works. It’s your way of putting a person on a scale and show they’ve lost weight.
Acupuncture is a phenomenal profession, but you have to make sure how do I navigate to continue to increase my patient base, which means also increasing your volume of patients by volume of income. Because ultimately, remember, you are a business provider and we’ve got to make business decisions. So I always want to be there to help you navigate that as the American Acupuncture Council does.
So until next time, my friends, I wish you the very, very best.