Weighing the pros and cons of taking insurance as an acupuncturist
It’s the infamous question you get asked daily isn’t it? “Do you accept insurance?” “Does my plan have acupuncture coverage?” We’ve heard them all. Acupuncture is moving up in the medical world, and patients are desperately trying to find acupuncturists that accept insurance and inquiring if their health plans will cover the benefit. The main reason patients are asking this is because they are thinking that they pay an insurance premium; why shouldn’t they be covered? Who could blame them? If we pay for something we expect results! Nonetheless, patients and acupuncturists alike are still finding their way with accepting and dealing with medical coverage when it comes to acupuncture, and which procedures are covered and which are not. Even major insurance carriers are still learning the ropes for acupuncture coverage making the job of the provider and their billing staff that much harder. Can you trust what the representative is telling you about a patient’s coverage? Are they giving you accurate information? In these instances, it is important to be diligent and stay one step ahead whether you choose to be in or out of network.
Pros and Cons of In Network
Let’s face it, everyone has an opinion on this, and it’s hard to influence one way or the other. Instead, let’s take a look at the issue of accepting insurance objectively. Just like with every other decision that needed to be made for your practice, there are pros and cons to them all. Accepting insurance is a beast of a process no matter how you look at it. The other side of it being out of network can be difficult dealing with and getting patients to come in regularly. This list will hopefully give some perspective one way or the other if you’re on the fence…
- Affordable. Services are more affordable for patients which leads to having more patients walk through the door. Patients may also be able to come more frequently (typically 12-15 treatments covered per year if acupuncture is a covered benefit.)
- Marketing. There are lots of marketing benefits to accepting insurance. In network providers have their name published in that particular insurances directory which can drive patients to your practice, and most new providers are almost immediately available on the internet.
- Lucrative practice. While some insurance companies pay less than most acupuncturists charge, others pay more, and for the most part, more patients, even at less pay, means more money to the bottom line. This may also mean the patients are more apt to follow through on their treatment plan and come more frequently. In addition, this may also mean a patient who might not normally try acupuncture might because their insurance covers it.
- Diversity meaning having a mixture of patients (cash patients, insurance patients, workers’ compensation patients, personal injury patients, and discount patients.) More diversity means more ability to withstand changes in the economy. For example, when the economy goes into a recession, the majority of cash patients will not be able to afford acupuncture sessions, but those patients covered by insurance can keep coming without a major change in their health expenses.
- Paperwork. Likely a lot more paperwork.
Some in network applications can be 20 to 50 pages long, and that’s not
even the part that takes the most time. The follow up is even longer. It
can potentially take up to 6 months to get credentialed with some
- Potentially less pay per patient. Compensation
is variable depending on which insurances you are dealing with. If you are
going to be out of network, it is important to find out and keep track of
how your claims are paid to know what to charge and how to proceed moving
forward. Typically, insurance pays $40-$50
per patient visit and sometimes even less depending on the insurances fee
schedule which also can change
year to year.
- Delayed payment. The whole billing
process may take more of your time than cash patients. You may find that
payment is delayed because some insurances take longer than others to
process claims, especially those in worker’s compensation and personal
- Non-covered services. Insurance does not cover all diagnosis codes or services to which they deem “investigational,” “experimental,” or “not medically necessary.” Some services that acupuncturists are told they can bill out may not be paid at all depending on the insurance such as cupping, tuina, gua sha, manual therapy, infrared therapy, and even an office visit E&M code like 99203. You can then go through the process of a reprocessing or an appeal which will take up another chunk of time only to have it potentially still not paid by insurance stating they are upholding their decision per their contract with the patient. In addition, you have to look at diagnosis codes that aren’t covered. It is important to verify if insurance covers for pain management or only in lieu of anesthesia. Most insurance companies have medical policies on their websites for each specialty showing which diagnosis codes they deem “medically necessary.”
Being in and out of network both have their fair share of valid concerns. It is imperative to know your business model, and also be honest with yourself as to what kind of practitioner you are as far as organization and desires for your practice.
Is the Patient Covered?
Additionally, for both in and out of network, if you decide to bill insurance companies it is vital to know what you’re up against when contacting them regarding a patient’s coverage for acupuncture. As stated above, acupuncture is indeed on the rise, but insurance companies are still getting used to what their benefits have to offer and may not be fully aware of all the information you may need to move forward with submitting your claim.
There are a few important things you want to get out of verifying a patient’s benefits:
- Whether you are in or out of network, it may
be wise to check on benefits for both. This way, you are able to determine, for
the most part, if that particular insurance company is worth going in network
for in the future or if you prefer to stay out.
- Covered services meaning acupuncture, cupping, tui-na, etc.
- Lastly, covered conditions. In the case of insurances these would refer to the diagnosis or health issue the patient would be coming in for.
Some insurances will advise you to check benefits online, however you almost always will need to check benefits by phone in regards to acupuncture as it is not usually a benefit shown in online portals.
There are steps and key information that you need to obtain when making the call:
- Once you get a provider services representative, let them know you are a
service provider (or calling on behalf of the provider if your billing
department is making the call) and you need to verify in and out of network
benefits for acupuncture for a
- They will then ask you for the following bits
of information before proceeding to verify you and the patient you are calling
on behalf of: provider name, tax ID number (TIN)/national provider ID (NPI),
office address, patient name & date of birth (DOB), and patient subscriber
ID number (if you do not have the subscriber ID, most insurances can still
verify if you have the patient’s social
- Once you and the patient are verified, you will need the following information for in and out of network acupuncture benefits: copay (paid at the time of service,) deductible (the amount the patient needs to meet before insurance will pay a dime,) coinsurance (the percentage the patient is responsible for in a particular service,) and lastly, out of pocket maximum (the most the patient has to pay for covered services within the plan year.)
Once these logistical steps are out of the way, there are four key things you will want to be sure to ask:
- Does the patient have coverage for acupuncture if performed by a licensed acupuncturist? There are some insurance companies that will pay if the session is performed by an M.D. but not an acupuncturist.
- Is the patient covered for pain management or only for in lieu of anesthesia? There are many plans out there right now that will tell you they are covered for acupuncture which is true to an extent, however, being that most acupuncture patients are coming in for some form of pain, this is not 100% accurate information. Therefore, it is important to ask while on the line with the representative because again, they may not realize this is an important piece of information for you.
- Give the representative your 5 (most insurances will only take up to this amount) most used CPT (procedure codes) and ICD-10 (diagnosis codes) to check if they need a pre-authorization or pre-certification under the patient’s plan. You will also want to ask them if there are any restrictions for the acupuncturist specialty type for any of the codes provided.
- Last, but certainly not least, the most important piece as long as you have obtained all of the above information is to get the representatives name and a reference number for the call. This reference number is key! If you have this number, it is something that could be used down the road for potentially reprocessing a claim if the information given on the call for benefits was contradictory to the denial.
Having more information than you need is always good when submitting claims to insurance. Doing things this way will always cover you.
Should I Play the Insurance Game?
We know, we know, we haven’t really answered your question, have we? Well, the truth is there are benefits to both in and out of network as well as cash only practices. As far as in network, if you decide to go that route, the most important thing of all to remember is that it is not something that you can expect instant results from like cash. It can take a year or more to see results, and it cannot be dabbled in for a short period of time and given up on. Above all, read the contract. If you do not agree with any of the terms do not sign. If you choose out of network, just make sure that you stay organized and do your due diligence when it comes to figuring out what insurances will pay you. There is a lot of trial and error with out of network, but once it is figured out, the possibilities can be great. Finally, if you decide to keep your practice cash only, you need to make sure to show your patients the value in paying cash for a service. Value, many times, out rules any cost, especially if the patient is truly suffering. Another option for cash practices would be telling a patient to check if they have HSA benefits which could take care of some costs. It feels like at this point, the pressure of playing the insurance game is inevitable, but at the end of the day, the choice is yours.