Insurance — Ensuring Trouble?

“The insurance company used to pay this code, now they won’t, what can I do?” or “Why are they asking for preauthorization all of a sudden?” Questions like this have suddenly become common in acupuncture discussion groups. I believe that until recently, most insurance companies in most jurisdictions saw a relatively tiny number of claims related to acupuncture services. Now, as more practitioners and patients take advantage of increasing coverage for acupuncture, we’ve crossed a threshold. Some companies now pay out enough for acupuncture services that it has become worth their while to pay closer attention to claims.

Given the cost of conventional medical care (greatly related to technology and Big Pharma) insurance makes sense. It is easy to imagine circumstances, and many of us don’t have to imagine, in which one could owe tens or hundreds of thousands of dollars for medical care. That isn’t the case with acupuncture.

It’s great if you’ve decided that part of your practice will be working with insurance. It is nice that we have the option. For some it signals that “we’ve arrived.” It helps our acceptance and it enables us to reach a population that might not otherwise consider our medicine. Currently, acupuncturists who know how to work well with the insurance system may do well with their reimbursements, coming close to matching their regular fee.

Please, though, be aware. The more your income is controlled by the insurance companies the less control you have . And the more our profession depends upon insurance the more power that industry has over our medicine. If the industry decides to cut reimbursements, or to further limit the codes they will cover, or the number of treatments they’ll cover (and if we look at the experience of other professions we know they almost certainly will) we may find ourselves stuck.  If the insurance industry determines they will only cover acupuncture for back pain will that influence even those paying out of pocket?

Some practitioners are not working well with the system but are instead working the system — billing for more units of acupuncture than they perform; adding additional services to the treatment, or even worse, just to the bill; using ICD codes that get reimbursement even if that isn’t the focus of treatment. They sometimes cross the line into fraud, though they believe they have good justifications for doing so. Big Insurance is unlikely to agree, and that will reflect upon all of us.

Personally, I’ve made the choice to discount my fee directly to my clients. I find it much more enjoyable than getting the same amount only after a painful dance with the insurance industry. It’s great if you make a different choice. But don’t forget that with greater participation comes greater scrutiny. When you play with the insurance companies, they set the rules, and they can always find a way to win, even when playing with professions far more powerful than ours.



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© Elaine Wolf Komarow and The Acupuncture Observer, 2013-2033. 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.

6 thoughts on “Insurance — Ensuring Trouble?

  1. Elaine,

    You correctly point out the problems of dealing with insurance but that is only side of the issue. The problem is more complex.

    As I sense the direction of the profession, many people are pushing to have acupuncture covered by insurance companies. As more insurance companies cover acupuncture it will become increasingly difficult for acupuncturists who do not take insurance to attact new patients This may not be a problem for established acupuncturists but it will confront new practictioners.

    What we should be focusing on, is how to avoid the fate of other health care providers who have seen their incomes steadily decline over the years as insurance companies and the Government pay them less each year.

  2. Thank you for writing thoughful and comprehensive articles. I agree the conversation needs to start.

    My personal experience with insurance was awlful. I gave up. After long waits on the phone, repeative lost claims, conflicting information from customer service, I couldn’t make a profit. Plus many insurance companies don’t want to cover for a full treatment plan and left clients high and dry. Then these clients end up leaving frustrated since they can only afford to a copay.

    The personal joy I have with the profession is spending time with clients. Often they need to be heard and help with thinking through their health concerns. Insurance companies don’t recognize or value this as part of the healing process. I found to make a profit at insurance I would need to see a larger volume of clients. Is the quality of our profession to follow western medicine?

    I find out of network benefits to be the best of both worlds for me and the clients. I help (free of charge) to fill out claims, figure out appropriate ICD codes, make phone calls and even write appeal letters to denied claims. Many of clients feel the extra support in the process to be helpful.

    Plus, as my practice is an out of pocket practice, I am very open and truthful about the treatment plan, so clients understand the financial part. When a health condition is not responding to the acupuncture, I encourage open conversation with the client about possible extension of the treatment plan or referring them out. Generally, people appreciate honesty and the ability to voice any concerns.

    I am concerned about where our profession is going with the push to have insurance. Are we headed in the same direction as other modalities? Having to bill for moxa, heat lamp, estim and tui na to get a better payment? Why do so many other practitioners what to do acupuncture? Yup another procedure to bill for. Is this what’s in store for us?

  3. You are truly hitting on some hot button issues. I hear what you are saying and generally agree on your thoughts and comments. Where I was practicing people could not afford acupuncture. No, not even at a reduced price. For some if they did not have the insurance they would not have come at all. It truly helped them to be able to come. I had one patient with MS would was laid off with no job. I again do not have the answers but you do pose some interesting topics. I hope someone out there is listening. I hope you can make the necessary adjustments. Good Luck!!!

  4. All good points. However, discounting our fees is not a good substitute for taking insurance.

    Discounting fees has its own set of problems. Who gets the discount? Most of us assume it is right to discount in cases of low income or hardship. But what about discounts for a patient whose insurance would cover our services if we accepted their insurance? Is that fair to the other out-of-pocket patients? Then there are “senior” discounts, usually based on the fixed-income idea. Yet many seniors live on very high fixed incomes, often much higher than the young family with two working parents. There are all sorts of other group discounts- student, military, church, etc.- to consider, all with specific rationales. Package deals are another common form of discounting, coming with their own issues of legality and medical professionalism.

    I’m not saying we shouldn’t give discounts. When we do discount our fees, we should do so with careful thought. What insurance companies do or don’t do should not be our motivation.

    • I hear ya. Personally, I have been happiest when I have spent less time figuring our who deserves a discount and instead leaving it up to the patient. After all, I have no idea what other circumstances the person is facing. Maybe they make a great salary but are supporting their elderly parents, for example. It doesn’t always seems fair, but overall it feels fine, and I make sure each and every client knows that discounts are possible if needed.

      Similar fairness issues come up with insurance — the executive making over a million gets the super-duper insurance that covers everything, the poor gal on the factory floor gets something far less generous.

      In any case, my motivation is not what the insurance companies do, but rather my desire that people who want acupuncture can get acupuncture, and my experience that I am a lot happier when I am the one calling the shots rather than a third company that knows about the situation only from codes on paper.

      I’m certainly not wanting to give the impression that I think the practice that discounts is better than the practice that is built around insurance reimbursement. We have room for and need for all different types of practice. My purpose for this post is to call attention to the bargains we make. When we give the insurance companies the power to define us and to set our fees and determine who gets what discount — well, then they have the power.

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