Acupuncturists and Medicare, Questions for the AAAOM

I’m thankful I spend my days helping people. I’m grateful I’m my own boss and that I’m able to treat every client as a unique, complex, individual, not as a diagnostic code. I could write a whole post on what I’m thankful for, but, this coming Sunday, it’s time for another AAAOM Town Hall. There are other things I’d rather be doing the evening of December 1, but I plan to participate, and I hope you will too. So, before we head off to sweet potatoes and cranberry sauce, here are my questions for the AAAOM —

  • Given the current political climate and the current level of involvement from the profession, what are the odds these bills will be successful within the next 5 years.
  • How many LAcs intend to become participating providers in the Federal Health Programs?
  • Does the small number of contributions from practitioners to the AAAOM legislative fund indicate that this effort is not a priority for the community?
  • Given that there are fewer than 30K active licensees in the US, and that not all will participate, could legislative success benefit other professionals who use acupuncture more than it helps LAcs?
  • Do the Medical Acupuncture and the Chiropractor communities support this legislation? Will they participate in the legislative effort?
  • Many LAcs treat Medicare beneficiaries. If acupuncture becomes a covered service won’t LAcs who opt-out lose most of that portion of their clientele to providers choosing to participate?
  • How many LAcs are providing acupuncture via the Medicaid system in the five states that permit it?
  • Is it possible that the opt-out provisions could be stripped as part of the legislative process (related to the small number of potential providers)?  Would the AAAOM be able to stop the legislation if that happened?
  • Can you clarify the distinction between enrolling, participating, and opting in?
  • On page 8 of the FAQ it refers to patients falling into the opt-out exceptions.  Is it providers or patients who opt out?
  • On page 10 of the FAQ it states that the legislation will not require LAcs to use electronic medical records.  Is it true that participating providers will be penalized a percentage of their reimbursements starting in 2015 if they do not use EMR’s?
  • If you opt-in, and the beneficiary reaches the limit for their number of treatments and/or wants treatment for a condition that isn’t covered, are you able to treat them and bill them for those services?
  • If you opt-out could you still treat Medicare beneficiaries who have surpassed their treatment limit without impacting their future benefits?
  • If opting-in, can practitioners limit the number of Medicare beneficiaries they accept as clients?

There are other things the AAAOM could focus on that would be more helpful to the average LAc and be more likely to succeed. But this Town Hall is limited to the AAAOM legislative efforts. I am thankful they are asking for input, and I will oblige.

Happy Thanksgiving everyone — and thanks for reading.

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.

22 thoughts on “Acupuncturists and Medicare, Questions for the AAAOM

  1. Glad you just distilled lots of the important considerations in the proposed Legislation.
    I’ve read through and now have a way of asking questions as I’m reading. Really jammed but will try to be there for the Town Hall!

    • Thanks Pete. I hope to “see” you there 🙂 The comments here support my feeling that the AAAOM has put the cart before the horse with this. They’ve hired a lobbyist and bill writer, and gone through several rounds of comments, but there still seems to be a lot of questions and confusion among practitioners. There are people who specialize in policy analysis and who have studied the impact of Medicare on other providers. Wouldn’t it make sense to get them involved before we are writing bills and pushing for passage? And those of us writing in have been following these issues more than the average practitioner.

      The AAAOM has a very small membership at this point — maybe 500 professional LAcs, and most of those within their first years of practice. Yet they seem committed to move ahead with this legislation that would affect every single one of us. How many LAcs would answer “Very Likely” if asked whether they would participate? Most of those I’ve found who say they support the move don’t understand much about what it would mean for us and also say they don’t personally plan to participate.

      The odds of this legislation being successful are so tiny that I’m not all that worried about it. What worries me is that a group that purports to speak for the profession seems so out of touch with 1) how to run an association (see: small membership, lack of activity in an area other than federal legislation, lack of useful information and professional tools on the website, etc. Why do I see colleagues trying to come up with their own solutions or answers when confronted with an insurance question, a subpoena…). They seem to be playing this game — we are the only national professional association, we are speaking for the profession and, we need to honor the demands and desires of our membership, and they agree with our pushing this legislation. Well, those of us who have seen the leadership of the AAAOM do whatever they want have stopped being members (I’d be interested to know how many former board members are still members of the association), so, the only folks left are people who agree with their position. The AAAOM should be clear in all of its communication that it speaks for X number of LAcs and stop pretending they are the voice of the profession.

      A weird thing about the Town Hall invitation is all the stuff about organizations and representation. I’m not really sure what to make of it — this mainly seems to be an informational session. It will be interesting to see who shows up to this.

  2. I found the following information on a chiropractic website:
    Examinations, x-rays, other tests, etc- Not Covered
    Exercises, therapies, doctor counseling time, etc- Not Covered
    Orthopedic supplies, dietary supplements, etc-.Not Covered
    Spinal adjustment 2013 fee $40.26, 2013 Medicare pays about $28.00, remainder $12.26
    “Medicare does not give a specific number of adjustments per year they will pay for, but some of our patients have told us that Medicare told them that they can expect to have about 20 visits per year to be covered.”
    So the patient ends up paying 12, the doctor after much time and tribulation may get another 28. And it only covers a fraction of what they actually do.

    • That’s true, but it has nothing to do with the enroll/enroll opt-out/par/non-par/don’t bother enrolling at all issues. Chiropractors and Physical Therapists are among those professions which cannot opt out.

      My understanding is that you do not have to be enrolled in Medicare to provide non-covered services to beneficiaries, ans you do have to be enrolled to provide covered services.

      Presumably a Medicare patient could retain their favorite chiropractor for the non-covered items for which that DC. can legally bill, and see an enrolled Medicare chiropractor for the covered procedures which an un-enrolled doc can’t provide.

  3. A little more on the topic with links.

    The issue: Providers cannot accept payment from “Medicare beneficiaries”, i.e. seniors, unless they enroll in Medicare.

    For us, if a law is passed including acupuncture as a Medicare benefit, this might mean that we cannot legally accept cash payment from seniors, including existing patients who come of Medicare age. If the law includes “opt-out”, this means we cannot accept cash unless we enroll in Medicare and then opt-out, which has its own set of rules and regulations. In either legislative case, if we want to continue to see our Medicare covered patients, NOT ENROLLING IS NOT AN OPTION.

    Here are links to two of the better PT blogs on this topic:
    http://www.webpt.com/blog/post/medicare-issues-facing-cash-based-pts
    http://www.drjarodcarter.com/accepting-out-of-pocket-payment-from-medicare-patient/

    Here’s another link. Read Background on page 2.
    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0908.pdf

    Not as useful, but interesting in that it’s from the chiropractic equivalent of Acupuncture Today.
    http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=37067

  4. @ Scott No, it is NOT like regular insurance. As far as I can see, from volumes of information, in order to treat “Medicare beneficiaries”, i.e. pretty much all seniors, one must enroll in Medicare. There is no option to just not enroll.

    To make matters worse, all information available from Medicare (and from most sites dealing with these questions) assumes enrollment. Any search you perform to find out what happens if you don’t enroll at all comes up with documents with the underlying premise that you WILL enroll. Section 40.13 in the Medicare Benefit Policy Manual covering “physician/practitioner who has never enrolled in Medicare” assumes that the solution is for that physician to enroll and opt-out. There is no discussion about not enrolling in the first place.

    Websites that have touched on this issue in any real way are chiropractic physical therapy, and psychiatric.

    Forget about the opt-out provision. A more important question is: What if we don’t enroll in Medicare in the first place? Can Medicare beneficiaries pay us out-of-pocket with no involvement or notice from CMS/Medicare if we aren’t enrolled in the system at all? The answer seems to be no.

    If anyone from the AAAOM town hall meeting answers this question with “yes”, get the exact reference, and research it on the spot on your preferred device.

    Enrollment in Medicare is a requirement for anyone providing the services Medicare will cover. If you aren’t enrolled you can’t treat them for compensation. (Hey, maybe you can’t treat them without compensation either. I bet that one’s even harder to research.)

    • @ Kathleen,
      please provide evidence that supports your assertion that a person who is receiving medicare benefits cannot currently go to an acupuncturist and pay out of pocket–they either have to use medicare for the service or they can’t get the service at all even if they pay out of pocket, as that seems to be what you are saying. As Elaine had pointed out, a medicare beneficiary can pay out of pocket for services, but will be held to paying out of pocket for 2years. I am not aware that acupuncture is covered by Medicare, if so, then the MDs, DCs, and PTs are providing it. I have no issue with that. If LAcs feel they’re missing out on this, then, well…I guess it sucks to be them.

      I’m not advocating that LAcs participate or not in medicare/insurance. What I have stated is that Medicare is a necessary benefit for seniors to ensure access to medical care. It was my seemingly incorrect understanding that the pathway for LAcs to gaining access to insurance reimbursement was for the occupation/trade (or profession) as a whole participates in Medicare, whereby individual providers could then opt-out. It seems to go hand in hand: Can we name a health provider profession that accepts insurance but, as a whole, does not participate in Medicare? PTs, DCs, OTs, MDs, DOs as professions all accept Medicare, but there are those that opt out of the system. Perhaps my understanding is that providers must participate for a period of time before they could opt out; i’m probably incorrect. Physicians, as a profession, participate, but many opt-out/may no longer accept new patients receiving medicare benefits, but still are eligible for private insurance reimbursement. Hospitals and community-based (ie. non-profit) clinics must accept medicare and medicaid and must provide a certain amount of charity care per year in order to maintain non-profit status.

      While LAcs and other providers may complain about insurance reimbursements and medicare payouts, they are necessary for the public to gain access to care. There are physicians who are foregoing accepting insurance and either doing the “boutique” route (pay me XXX dollars upfront and you can have XXX visits), or going the community sliding scale model. However, with ACA, I suspect this may change.

      • FYI, Chiropractors can’t opt out. Most eye care and most dental care isn’t covered by Medicare. Also, insurance and Medicare are not necessary for seniors to get acupuncture care — community acupuncture, LAcs working at public health clinics, practitioners providing senior discounts are all possibilities.

        In general, though, this all confirms my belief that there are a lot of details that we need to know before we hop on this band wagon. I’ve seen a lot of practitioners speaking with great assurance about Medicare, discounting services, participating, not participating, etc., even though they are wrong. Every LAc should know exactly how they’d be impacted by Medicare coverage for acupuncture before they come out in favor of working toward this change.

      • There is nothing prohibiting acupuncturists from treating Medicare patients at this time. And I’d like to keep it that way.

        I’m commenting on the proposed legislation that would bring acupuncturists into the Medicare system. There is no option not to enroll with Medicare. It’s enroll or enroll and opt out, but you can’t just not enroll at all if you want to treat Medicare patients for a service covered by Medicare.

        I provided a few links in the post below, already pubished.

  5. Thanks for posting the town hall info. I hadn’t heard one word about this, even though it says on the AAAOM website that they notified licensees. None of my health provider friends like participating in Medicare. I can’t imagine that acupuncturists would like it any better.

    • One of the problems we LAcs are facing is no good news source/information distribution. I believe the AAAOM may have been depending on state associations to spread the word, but some states don’t have functional associations and the groups in many states seem to be struggling.

      From what I know of my short time on the AAAOM Board, there are a few people who have made these bills their raison d’etre and they are going to pursue them regardless of what anyone else thinks. The good news is that I don’t believe they will be able to get very far with them, the bad news is that we’ve got a very few people pursuing action that will impact us all, and there doesn’t seem to be a way to get them to stop.

    • Unfortunately (or not…guess it depends on what end of the spectrum you are on) Medicare is necessary as it allows seniors to obtain coverage for medical/health services. We can all comment/complain on how this system is terrible, but for those that use it, it’s their safety net. We all pay into it via taxes to ensure seniors get their share of healthcare access.

      Because of how Medicare is structured, it’s necessary to purchase supplemental insurance. Also, medicare does try to contain costs by telling providers and hospitals that they will only pay x-amount for visits/procedures/hospital stays based on normal/customary fees and typical length of stay for procedures.

      Sure there is red tape, reimbursement may take a long time, and what is payed out is minimal. However, if healthcare were truly state-run, the physicians would be employees of the government and would be paid accordingly. So instead of making say $350-750k for surgeons, they would make somewhere in the ballpark of 150-400k, Internal med physicians would probably fall in the 100-200k range…not something to turn one’s nose up at. (figures are based on very rough salary ranges for providers who are employees of the county i live in). Also, it would be a flat rate. Currently, there is incentive to do procedures to increase billing–how do you think DC’s have worked the system? They tack on code after code after code after code, then submit. Of course DCs got slapped with fraud (which they were doing), and of course there are questionable codes for physicians/hospitals.

      But this is not the case.

      The questions are iif you don’t like Medicare, do you have any other solutions for people (patients, not providers) that require it? If you don’t like medicare, what do you currently do in your practice to ensure those that don’t have means to pay 60-120 per treatment to treat them? Do 25% of your patient pay a reduced fee say 20-30/treatment? What percentage of pro-bono treatments (or charity care as is termed by hospitals) do you provide?

      I practice very little nowadays, but I do work in healthcare and see incredible disparities, which I’m not sure many LAcs fully appreciate (except for the POCA folks). I’m sorry, but much of the arguments LAcs are stating sound like this: “I want to be able to make money (and yes, I do know a couple of LAcs that make 6 figures), or make a living, I want to be able to make a living/make money on my terms and my terms only, I demand to be accepted by the medical establishment, I will not be a second-class provider, I demand to be equal to a physician, I don’t want to be told how much I will receive for participating in medicare (which is the gateway to insurance), I want insurance, but I don’t want to treat anyone who is on medicare, I want what acupuncture to be solely the domain of LAcs, and not anyone else.

      • Scott, I appreciate a lot of your points here. I agree, we as a profession need to think about how we are going to serve everyone. This magical thinking that everyone will be able to get acupuncture, I will be able to charge what I think I am worth, I should be able to treat people exactly as I see fit with no one telling me how or what to treat, and I should be able to protect myself from any competition from other providers is all nonsense. There is no magic money here and there are some hard realities we must face.

        Chasing Medicare coverage plays into the LAc fantasy of having the “respect” of the system and having loads of clients, but there hasn’t been a hard look at the price paid. I would argue that what we think of as the failings and limitations of western medicine (seeing people as test results, little time being listened to by DR’s) has more to do with the impact of the third-party payer system than the underlying paradigm of the medicine. Fool’s rush in…..

        Until we get a real understanding of the implications of chasing the third-party dollar, we’re foolish to see it as the answer to our problems.

  6. Those are great questions and I’m glad you’re asking them! Would you be willing to post the answers that you get here also? (We’ve got WCA’s holiday party that night, so I’m not available to attend.)

    • I’ll certainly post any answers I get. The description of the Town Hall makes it sound like they are trying to keep it well locked up. A holiday party sounds like a lot more fun. Please send festive vibes my way to sustain me as I 1)Listen with respect, 2) Respond Constructively, and 3) Limit my topics to the federal legislative efforts 😉

  7. My biggest issue with Medicare is that we in order to treat seniors at all we must enroll or enroll & opt out. If we were to ignore Medicare or not enroll at all, it will be illegal for us to treat seniors for compensation. No one ever addresses this fact. It’s either enroll or don’t treat them for Medicare covered services – even if they have enough money and are perfectly willing to pay out of pocket.

    • I’m still trying to get very clear on the whole enrolling/opting-out distinctions. If there is an opt-out, and the patient agrees, I gather we could still treat them and bill them. But it is confusing. I think practitioners should also realize is that if they were to opt out I suspect many of their Medicare eligible patients would go elsewhere, even if they had the option of continuing.

      While I don’t think the legislation will progress, it’s hard to ignore it. If it did pass, it would impact every one of us. Given the way the request for comments was worded it doesn’t seem as though the AAAOM is willing to consider not moving forward with this.

    • I thought it was pretty simple. If you opt-out or don’t enroll at all and the patient wants to see you and pay your full fee out of pocket, there is nothing to prevent that. I thought it was similar to insurance: If I want to see a particular provider and they don’t accept my insurance/are not in my network of providers, I can still see them and pay their full rate.

      That said, with HMO’s there is now something called a “self-referral” which allows a patient to see a provider and get partial coverage–something in the ballpark of 50%.

      If LAc’s want to accept/bill insurance, then participating in medicare is the route to it. I’m not saying all LAc’s want to participate, but there may be those that do. No one is obligated to accept insurance of any kind and can run a strictly cash-based practice if this bill passes. All this does is potentially create access for people who pay into a plan and have it covered by their insurance. However, some insurance plans will only cover acupuncture if performed by a physician or a DC. Optional FSAs may not always allow you to use the funds you pay into for acupuncture. I believe FSA may only allow you to use “normal and customary” fees for services, however, I am not completely certain how FSAs work/what they cover.

      • Hey Scott, thanks for your comments. I don’t think you are correct on all points, and until we, as a profession, know for sure some of the answers, we shouldn’t proceed.

        First off, I don’t think there is the option of not enrolling. I think if we are on the list of providers we must enroll.

        Secondly, you assume that there will definitely be an opt out. I know that the AAAOM is committed to an opt out, but that doesn’t mean they will get it. The MD’s ad DC’s, who already have to enroll, might support this legislation because it gives them the opportunity to bill for an additional service. If any legislator points out that, hey, at most there are 20K LAcs, if we have an opt out there are no where near enough to serve the population, let’s drop the opt out, and the MD’s and DC’s still want the legislation to pass, we might not be able to stop it.

        Third, if you opt out, any Medicare beneficiary who chooses to see you and pay full rate also must agree that they will not have Medicare cover any acupuncture services for two years. Maybe your existing clients would agree, they know you are good — although even then they might worry that you would move, or close, or go on an extended vacation and they would be stuck. But a new client might well think, why would I agree to limit my options for the next two years just to see this guy. The same limits don’t happen if someone chooses to go outside of their insurance network.

        I’m not sure why you think participating in medicare is a necessary part of participating in insurance. A number of states have acupuncture as an Essential Health Benefit and many acupuncturists do participate, even though we don’t get have Medicare participation.

        Soon, I will write about how insurance coverage of acupuncture is impacting us all, even those who choose not to participate, but that is for another day. The issues of insurance companies covering acupuncture only if performed by an MD can be addressed in other ways. As for usual and customary — Medicare reimbursement would be limited to that to.

  8. Ugh…..again. Is there a possibility we wont be able to opt out of the medicare system? This is ridiculous. The medicare system pays terribly. What would be our reimbursement? $15? $20 for a session? Why are we doing this to ourselves? I can’t believe we have such a poorly run organization. What are the political connections of these people? Somebody has their hand in the cookie jar, because anyone with any sense wouldn’t be marching down this road.

    • The AAAOM has stated clearly that they won’t support a bill that does not contain an opt-out. The problem is that legislating is a messy process, so that is why I am asking if it is possible that a bill could move forward without their support. I don’t really think these bills will go anywhere anyway, so I’m not worried about what will happen. Do you think our legislators are eager to get involved with more health care bills? But the bills and our profession’s thinking about them give us an opportunity to consider our underlying assumptions and our strategy. For instance, everyone is concerned about the opt-out, because many of us don’t want to participate. So, if the bill did pass, and we all opt out, what happens to all of our patients? Most of them are likely to go elsewhere. The opt-out may solve some problems, but it creates others, so people need to think beyond that.

      If you click on the link to the faq you’ll see some discussion of the reimbursement rates. The current calculations look like the rates won’t be all that different from the insurance reimbursements. My bottom line is that regardless of the reimbursement rates, it is a mistake to put so much energy into a system that mostly shuffles money around. I’m all for providing for folks who need medical care and can’t afford it, but when it comes to acupuncture, there are more efficient ways to do that then getting involved in this bureaucracy.

      I don’t think the issue is folks with their hand in the cookie jar. I think there are a few people in positions of power who are convinced that this is the best for the profession. They have managed to surround themselves with others who either agree or are too timid or powerless to disagree, and so the train keeps moving. I believe the intentions are good, but, as you say, not sensible.

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