Acupuncture & Insurance, Part 1 – Universal Impact

“It’s fine if you don’t want to take insurance/participate in Medicare, but don’t stand in my way. If you don’t want to participate you can make that choice.” — that’s the sort of thing practitioners pushing for insurance coverage of acupuncture lob at those who express reservations.

Although I personally believe third-party payer influence will be bad for our profession and our medicine, my greater concern is that most of those pushing for these changes have a limited understanding of how we will all be affected. If the profession as a whole understood what’s involved and still thought it was a good idea, I’d get off my soapbox. In the meantime, I’ll do my best to provide food for thought.

I have a client who is financially comfortable and she paid my fee for years without a second thought. At some point, her insurance began covering acupuncture. I collect full payment at the time of the treatment and provide a receipt which patients can submit for reimbursement if they choose. My typical treatment includes two sets of needles so I divide the payment into a 97810 and a 97811 code.

One day, though, I came into the treatment room after the first set of needles and there was that feeling of a great treatment. The room was peaceful, the patient was glowing, the pulses were balanced and lovely. Anything else I did would not make the treatment any better and most likely would make it worse. When I told the patient her pulses felt great she said, “I can tell.”

Before meeting her at the front desk, I spent some time struggling with her receipt. The treatment had still taken 50 minutes. But I hadn’t done two units of acupuncture, so I couldn’t use two codes. So, I used my 97810 code, and put the additional amount of the bill under other services, with no code.

This meant that the patient’s reimbursement was less than she expected, and she, of course, wanted to know why when she came for her next treatment.  I explained that I had done only one unit of acupuncture instead of my usual two. The conversation then covered why I couldn’t bill for two units even if I had only done one (fraud), why I couldn’t have just done two units even if she didn’t really need it (also fraud, plus, not good for her), and why I charged her the same amount as usual if I had done less (I set my fee based on my time, not the number of needles). My client, who had never before questioned my treatment decisions and had been happy to pay my full fee before insurance gave her any reimbursement, was now an unhappy client.

Do I refuse to give any receipts to avoid this issue? Do I lower my rates if I do only one set of needles, even though, since I don’t know what will be needed in advance I still have to schedule the same amount of time?

Let me know what you think, but, here’s one thing I know. Don’t tell me that my practice won’t be impacted by your efforts to have insurance cover acupuncture.

Copyright —

© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2017. Unauthorized use and/or duplication of this material without express written permission from Elaine Wolf Komarow is prohibited. Excerpts and links are encouraged, provided that full and clear credit is given with specific direction to the original content.

28 thoughts on “Acupuncture & Insurance, Part 1 – Universal Impact

  1. Well written. Insurance in a broken and corrupt system. Taking insurance will an albatross around the neck of the profession. I meet local physicians in the post office where I live with stacks of paper work in their mailboxes from insurance companies. They tell me how lucky I am that what I do isn’t covered. I know many PTs and Therapists who have resigned from insurance. Just wait until a company comes back to you 6 years after you’ve rendered treatment and asks for $18,000 back. It is my great wish to retire before I ever take a dollar from an insurance company. I totally disagree that it is a question of “patient access” and I generally find this a pretense because the real bottom line is the imagination of making more money. Putting accountants in charge of treatment planning is not the way to develop a medicine that has integrity. Two thumbs down.

  2. Yes, you are right about the schools painting rosy pictures. They hold a lot of accountability. My two schools in CA are now out of business. You are right about the insurance and they way they work. If I function as an OT I can be paid differently which is the difference. I have investigated this fact. PT’s and OT’s are paid differently through the system than acupuncture that is why I believe it was important to add another modality. I am trying to make my life easier. I am a single parent with a child with learning disabilities which does make my case more challenging which is why my career takes a back seat. I still need to make a living and this was my solution. It will not work for everyone I reallize that but it works for me. I am concerned about the state acupuncture as a field and the direction it is heading and it does not look good to me. Our leadership is beyond terrible!!! Look at OT for instance no one, even today, understands what OT actually does and yet it is one of the top fields to pursue. How crazy is that? It is because of their leadership which we soarly lack.

  3. Hi Elaine: I totally agree with what you are saying.

    Well, the insurance system is not about seeing that patients get well – it is about controlling the flow of money, and in doing so, they essentially are limiting access to quality care. If we could only take a step back, and look at the big picture……. what has the third-party payer system done to docs and to chiropractors, and to other practitioners who now have no choice but to limit the procedures they do to what insurance will pay for? All of them must see more patients in order to make a living – I know one physician who has joined a medical group recently, because she couldn’t pay her bills – she was being reimbursed much less than the group. Now she’s on salary, but much more limited in the holistic side of what she had been doing on her own. So this affects other practitioners as well – the only difference is that right now it is to OUR advantage that insurance covers so few diagnosis codes, rather than ALL of them (at least in my part of the country – I’m sure that some states have a different experience).

    Why do I think it is to our advantage? Because enough patients will see that they are not covered and so they will pay out of pocket if they really want acupuncture. But we will have absolutely NO CHOICE once insurance pays for everything. It’s either participate in the system or leave the field, because our business will totally dry up.

    Do we really want someone else (who has absolutely NO IDEA about how acupuncture works or what we can do for the patient) to tell us what we can do with our patients? The thing is, Chinese medicine is a totally different paradigm than ICD-9 codes can ever represent. Yes, you can say you are treating shoulder pain, but really – if you see someone in front of you who is having shoulder pain as only one manifestation of a much deeper issue, perhaps simply that they are not living out their destiny, once the shoulder pain resolves but there is still more work to do to get at the root of the issue, how would you code that?

    I see only a lot of distraction from our real ability to make a difference if we let this happen. More time on paperwork and justification of the treatments we have been doing, time spent clarifying and copying files when the insurance company denies the claim. And spending time on the phone with the insurance company – I once had to make 5 calls about a case that was previously covered, and the insurance company no longer accepted the same ICD-9 code for migraine — when I asked which ones they DO cover, the answer was “Oh, I can’t Tell you that.” Really?

    Be careful what you wish for.

    • Pat
      Well said.
      I don’t see massage therapy going after insurance. I do see a bit of advertising the healing effect of MT. It’s something to spoil yourself, an investment into yourself.
      Why can’t we follow that idea?

      We get those complicated patients who don’t fall into the traditional treatment process. Complicated knotted patterns. How would that type of client ever get long term acupuncture coverage?

      Insurance is a black hole. No going back.

  4. I also have a child I need to raise and can not devote all my time to a business. Maybe before you start acupuncture school they should say “By the way, if you want to have a family don’t become an acupuncturist because you can’t do both!!!!” It is impossible to run a business, be a good therapist/acupuncturist, and raise a chlld. I don’t care if I am just treating pain or not. I am at least practicing which most of my classmates are not. There are some professions out there that you should not also be a parent maybe this is one of them. It starting to look that way more and more. It is easier for me to be a therapist work 9-5 so I can be a good parent too. I need to do what works. There are a lot of acupuncturist Mom’s out there that are also finding it difficult like myself. We do what we need to do not necessarily what we want to do.

    • Susan — There are people who do both — have a practice and raise a family, so it is possible. But not easy — especially if you have a lot of student loans and if you didn’t get good info about what is involved in running an acupuncture business. The schools are doing students a real disservice — presenting a rosy picture of opportunities, charging more and more for an education, and not giving good business training.

      • I am one if those people who supported three children as an acupuncturist. Yes, it is extremely difficult and I admit I spent those years overwhelmed and worried and overworked, in the beginning “moonlighting” at second jobs. Yes, it can be done but it’s really hard. I am grateful to numerous helpful friends and hope my children understand.

        However, I do not think it would have been any easier starting another kind of business, so I don’t blame acupuncture, and had we been a two-income family it would be easier. I guess what I’m saying is that when I think back on it, it was circumstances of all sorts that made it difficult, not my chosen profession.

        If acupuncture/Chinese Medicine is what they love, I encourage Susan and others to persevere. It is so worth it. Thankfully in my case, anyway. It’s really tough, and the family may want for a few things, but you are good parents and good examples to your children for it.

  5. My experience w/ integrity is it’s not always well-received. I believe ignorance is preferable to most people. Often the questions and attempt at understanding comes only after discomfort makes us ask the questions we didn’t have time or willingness to ask. Then we get pissed at the answer. More often, we blame the messenger. Call them names and insist our point is correct. It’s rare that we actually look at something with grace and openness and assume we don’t have the answer. That there are usually no simple answers. Keep up the clarity gathering and respectful dialogue! Respect is earned and the long run never lies.

    • Thanks, Pete.

      I believe most practitioners and most people have not been well-informed about how insurance is intended to work. There is this idea that it will enable patients to get the services they want with no limitations, and that the providers will be reimbursed at levels close to their set fees. Of course, when it doesn’t work that way, we complain about the evil insurance companies and feel justified in massaging the truth here, rationalizing a bit there, throw in a good dose of justification, and I’ve seen people come to the conclusion that gaming the system is the ethical thing to do — put one over on the man! But, it is the consumer who always pays, ultimately.

      Then again — I don’t think you were making that specific a point. Apologies for jumping off into my current swimming hole 😉

  6. It’s not insurance as much as it is having the knowledge of other modalities. How much do PT’s make in a session? Or OT? Or PA? They are getting paid regardless of what modality they are using. They get paid more for acupuncture than we do for less amount of time. That ‘s what it is. You may not care right now but down the line if the economy tanks which I believe it will anyone who does not take insurance will be in trouble. Maybe not you if you have a wealthy client base. I was sick of just treating certain kinds of people and not everyone. We miss out on other types of situations and people. This is just my thought. I am not saying you must agree with it. I have been an acupuncturist for 14 years and most of the people I went to school with are no longer even practicing. I think it is truly a shame what has happened to our medicine and where it did not go. I still plan on practicing but practicing under the OT/acupuncture route without building a practice. Working in a rehab situation with PT’s, OT’s, MD’s and whoever else. I want to do my craft and my craft only. Not a business hat or medical biller or computer expert. I will be happier that way.

    • Susan,
      I think if you love running a business you can always have a successful business (how ever you want to define success). To run a business is constant work and to change marketing as the business environment shifts. It’s a constant challenge to be on top of the market. (That’s why I’m here on this blog, I want to understand what the future holds so I can prepare). It’s not environment for everyone. Some people just want to show up and treat people, which is ok…..except our industry doesn’t have that flexibility.

      The market will always provide opportunity to have successful business, but it’s work to figure out how to find that nitch. School never prepares you for that. I think many acupuncturists don’t want to work the business and believe insurance will bring an instant practice. Nothing moves instantly and everything in a business is work. There’s no such thing as a free lunch.

      I personally love working for me. I don’t put up with personality conflicts and making my own hours. I can’t live without the flexibility. Of course, I’m giving up the security that comes with job.

      Since you work in a rehab center, do you only treat pain? Can you treat hot flashes? Or diarrhea? I would think since the rehab center is paid thru insurance you would be limited in the treatment process?

    • BTW, I don’t think it is true that PT’s, or any other provider, gets paid regardless of what modality they are using. Also, a lot of the work of PT is done by PT assistants — who are not making much. That’s one thing insurance has done — moved the most trained practitioners into manager roles, and they manage those with less training who are actually providing the service. The PA is getting reimbursed via the MD they are assisting….

  7. Hello Elaine,

    I apologize for the rant;) I would love to hear from others on how they work the system. Because I think it sucks for us.

    I’ve run into somewhat of this issue you are writing about. Clients asking me to change diagnose codes to get coverage. Rather than fertility, they want the bill to be coded for shoulder pain. Even though treatments have been fertility based and thus documented as fertility, they want me to change codes for shoulder pain. They don’t really understand fraud. They want to get paid. There is certainly pressure from clients to make sure the insurance pays.

    Clients also don’t understand that they couldn’t get in network coverage for every ailment. Its not like seeing your dr. Insurance won’t pay for treatment of a cold or bronchitis. Acupuncture is limited. So how are these acupuncturists getting coverage on all these unusual health problems? Like hot flashing, anxiety, insomnia?

    Some of my clients had unlimited out of network benefits. I’m noticing that is stopping. Insurance is limiting coverage to a set number of treatments and only covering ailments which have been researched to be cost effective (compared to other treatments). One client got pregnant with acupuncture (not covered by insurance) but the insurance was willing to pay $10,000 for IVF. There’s no research showing the cost effect of acupuncture. Thus no coverage.

    When a potential calls me, wants acupuncture for fertlity and wants to use insurance I wonder how acupuncturists get insurance to pay for the whole treatment term. Often fertility clients need 12 weekly treatments (3 months) to change up their menstrual cycle. I’ve had clients come months. No insurance is going to pay for long term treatment. I don’t think clients understand – they will not get a full treatment plan covered. In the past when I took some insurance I was limited to 6 treatments with the client. Further care was denied. She was making improvements but not fast enough for the insurance company. I felt so limited by this.

    The insurance system is forming us into the western system. Pump them in. Pump them out. Many of my fertility clients feel unsupport by the medical system. No one takes the time to listen to them or explains the process. Why? Because clinics can’t make money giving top notch care. If I took insurance I would need to see 4 clients an hour. That’s not how I want my practice. For me, listening to my clients gives me insight into point selection and development of the treatment plan. In fact, from the one conversation I was able to put pieces of her health puzzle together and referred her to a clinic to get help. She was very grateful because issues were diagnosed and treated. She then got pregnant. Insurance will never ever pay for that.

    If I’m ever forced to take insurance, I’m moving my practice into Community acupuncture. It’s such a better option than anything else out there.

    • I don’t think you’ll ever be forced into taking insurance, but as it becomes a bigger part of the profession it will certainly impact how we run our practices.

      From what I can tell, many of the practitioners who are more deeply involved in the system are doing things that are fraud — changing the way they treat to maximize codes, rationalizing diagnosis — as you said with the shoulder pain. So far, since insurance has been a tiny portion of insurance business it hasn’t attracted too much attention. This will change.. Already, in the states where acupuncture is an EHB, there seem to be a lot of reports of companies disputing payments that they used to pay without a hitch. I think those states will be a good reality check for the rest of us.

      • I’m actually concerned as insurance for acupuncture becomes more mainstream. There are plenty starving acupuncturists who will to do whatever with insurance to get paid.

        Though I believe insurance is getting smart about payment. As payment for acupuncture increases, they clapping down on claims.

        Never mind that it can take months to get payment. One client has unlimited acupuncture coverage. It took her six months after we stopped treatment for her to get paid. In fact I had to get involved to help her collect payment. Another client started 3 months ago and has yet to receive payment from the insurance. Do practitioners realize that “instant” clients mean hours on the phone and months to get paid? So what’s the difference between having a smaller group of cashing paying clients and a large group of insurance clients when you are waiting months to get paid? That’s still living hand to mouth.

    • Samantha, here’s my approach.

      Because I treat as much as I can in a session, I do not feel it is fraudulent to treat back or neck pain and fertility in the same session and bill for pain. But I won’t make something up or lead the patient into saying they have a condition they don’t have.

      On the phone I’m very clear that fertility (or asthma or whatever) is not usually covered, and that if we find a covered condition that I treat, then we’ll use that code. I also make very sure that they are OK with this being in their medical record. Once the neck or back feels better, we’ll no longer code for it and some sessions are likely to remain uncovered.

      I also translate things like asthma into chest pain – IF there is accompanying chest pain. An ulcer would be stomach pain.

      I don’t think of this as “working” the system. I’m very clear with the patient and only bill for what I do treat, and document with office notes.

      Sometimes I split the fee, billing for the covered codes and charging the balance as “uncovered acupuncture”.

  8. Remember, participating in Medicare is very, very different than dealing with other third party insurance. We can’t just deal with Medicare. We will be required to enroll in order to treat its beneficiaries. But we’ve been over this already.

    Yes, I’ve often encountered this kind of problem. On the billing end, I use 97810 with my full fee. I might or might not add 97811 for the additional time & set of needles. It’s complicated doing this. Obviously I don’t want to have the codes add up so that the patient ends up being reimbursed for more than my fee, so I only bill an extra set if I know for sure reimbursement is low. There are a few instances when I submit claims and receive payment from the company. Sometimes I’ll use two 97811s (because I did that much extra, no fraud). On the other hand, I have a WC patient – one of those few instances – whose insurance reimbursement is quite low. He only needs one set and I accept their reimbursement because it would be fraudulent to bill two codes. I also believe it to be fraudulent to split this treatment into two sets of needles and resent the temptation to play these games.

    How to explain it to the patient is a whole other problem. Only billing 97810 is an easy way around it, but I understand why you would want to bill two codes for complete reimbursement.

    And what about community acupuncture clinic? 97810, even when attached to a lower fee so the two codes add up to full fee, is still going to be higher than what CAC costs. We don’t deal with insurance in my community clinic for several reasons, and that’s one of them.

    Acupuncture is a big square peg fitting into a round hole when integrating into our massive and corrupt medical care system (you can hardly call it a health care system). There is a strong push, by both “us” and “them”, to plane us down to fit and conform. I urge more careful consideration and creative thinking about how we are to fit in.

    • Based on what the reimbursement levels are, even when I use two codes my patients aren’t getting more than 50% of their fee reimbursed. The insurance companies won’t pay more than your fee. Even if they would cover up to, let’s say $40.00 for a 97810, they won’t pay that if you only charge $15.00 — so it doesn’t seem to me that folks would get more than you charge. (But I am, for sure, no expert in this arena.)

      Mostly, I just wanted to give an example of how things like insurance coverage do affect the profession as a whole. This idea that you shouldn’t interfere with my goal for more coverage, it won’t impact you, isn’t based in reality.

      • Oh, I don’t think we interfere with each other’s goal for more coverage at all, or that our actions impact each other’s goals. Sorry. I thought you were starting a discussion on how we deal with insurance billing and the complications that arise.

        One point is – can we charge $15 for one person’s 97810 and $40 for another’s? I have a standard 97810 fee in my management software (we use Client Tracker). We discount off that on the superbill, but it shows the fee after discount on CMS 1500 with no place to note the discount. For different patients, 97810 will be priced differently. An audit would show this discrepancy. Honestly, it’s just plain complicated.

        • It IS complicated. And helping us sort out this confusion would be a great thing for organizations to focus on.

          I really don’t know the answer to your question — I think we are supposed to have the set fee and then discount from that, as you said. Never filled out a CMS though. Perhaps you could ask your state association to provide a seminar on this? (Though I have found that associations sometimes say things with great assurance than are not correct.)

          The goal of those pushing for more acupuncture coverage does interfere with my desire not to have to deal with insurance — as it is becoming the expectation of my clients.

          • Last June our state organization actually did have a very informative seminar given by Mori West if AcuClaims. It was geared to our state & a neighboring state. A great seminar, but people who do an official billing protocol often don’t have answers to the kinds of questions we ask here. For years I’ve been filling out CMS 1500s to give to patients, and for myself to send back when I was in networks (I’ve been on & off, always short-lived.) and came away with new and immediately usable info The beginner billers also got a lot from her. I recommend Mori to anyone thinking about a seminar.

          • Great — thanks for the shout out. Mori is generous with her help. She might be able to give you more info on the CMS and discounting if your asked.

  9. We have been impacted as acupuncturists since 2008 in one way or another. Some of us have been impacted fianicially and some in other ways but since then many of us have seen a difference. I agree with you. You seem to have a solid client base and good for you. I was starting a new practice and doing very well until 2008. I had to be honest with myself. I did not want to start a new practice all over again somewhere else. I had been a business major in undergradute and I hated it then. I do love being an acupuncturist/therapist. So, I decided to go back to school for OT to combine the two so I don’t have to build a practice any more. That is what works for me. I agree with you, you need to do what works for you. Like I said before I do not think acupuncture will be just acupuncture standing by itself as it has in the past. I think it will be coupled with other modalities going forward. You might have people paying out of pocket but I believe our economy will take another dive soon and it will be difficult for people to afford the extra money. This is just my personal opinion it does not mean I am 100% right. I am skeptical of our future as a country. I am protecting my ability to make a living. The acupuncture leadership has already failed us and I really don’t know what they think they are doing now. It is pretty pointless and they are making a mess of things.

    • Susan —

      The CA model enables people to get acupuncture treatment for less than the typical insurance co-pay. It is possible to structure a practice so that it is affordable for many. Also, I’m going to explore this more in other posts, but looking at what has happened with other professions, insurance reimbursement will not equal a better living for most of us.

      I’m sorry to hear it’s been so difficult for you — and for some many other folks trying to get started in the field.

    • Susan
      Sorry to hear business wise it’s been difficult for you. I appreciate your reply. Why? Because schools sell how easy it is to make a practice work….which is line of crock. Running a business for some…it’s not their thing. I remember being told in school about get hospital jobs that would be created in the future. Of course that doesn’t exist.

      I was lucky. I love running my business but it’s hard work. Never mind all that work after hours in training and reading to get better at the profession. Your reply is part of missing puzzle that doesn’t get get addressed by the big organizations.

      Question Elaine. Should we be pushing for jobs in hospitals? Not everyone wants to run a practice.

      • I’m not sure what you mean by “pushing for” — certainly if practitioners are interested in working in hospitals I support figuring out how to make that happen. I think there are some practitioners who have made it work — perhaps Eric Buckley in New Mexico. Interestingly, one of the arguments people have made for getting Medicare coverage for acupuncture is that it would facilitate our working in these settings. (I’m not sure it would, that’s just what people have said.)

        I think a challenge of working in hospitals is that in our system, people don’t stay in hospitals very long — I’m not sure how much good we could do in those settings. I think we’d have to show what we could offer that would be worthwhile.

        There are other options for folks who don’t want to run practices — PT offices for example, since supposedly we’re so good with the “dry needling” or other integrative practices, community acupuncture clinics, Kaiser Permanente facilities, etc.

        • Another thing about working in hospitals — what is a realistic amount to expect we’d be paid — and — how much would patients be billed for our services? In the age of $100.00 (or is it $50?) Tylenol, I suspect patients would be charged an incredible amount for our services. I suspect pay would be equivalent to what practitioners are paid in Community clinics. Working conditions — we’ll I’d take the CA clinic.

          • I’m thinking about all the effort pushing Medicare. Maybe organizations should be thinking about how to integrate acupuncture?

            Acupuncture in labor and delivery is a great place for acupuncture. Pain relief in oncology. Helping people pass in hospice.

            I think practitioners who don’t want to run a business could fill a niche. Really our profession is limited to sole practices.

            But you answered my question 🙂

            Thanks.

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