Accepting Insurance to Build Your Practice

In order to give practitioners the best chance to build a successful practice, I promote a model that encourages the broadest possible revenue sources and in the U.S. that includes accepting insurance. The biggest mistake many in the AOM profession make regarding insurance is not appreciating how to use it as a means of practice-building. If done properly, accepting insurance can be an important prong of what should be a multi-prong approach of building a stable patient base.  Only focusing on the paperwork or reimbursement rates without looking at the big picture of how the limits in acupuncture coverage can actually work to an Acupuncturist’s advantage is short sighted.  

It’s hard to give the most practical advice about accepting insurance to a broad audience because insurance is regulated by each State – although the Affordable Care Act is starting to change this (more about that in a later post). For most States, there will be a few basic types of insurance one could accept – health insurance, insurance for injured workers, and personal injury insurance.  There could also be State Medicaid plans although I am not sure what states, if any, cover acupuncture in those plans. Medicare does not cover acupuncture.

 I want to focus here on health insurance plans. This includes types in which providers (Acupuncturists) must sign an agreement with the insurance company or otherwise enroll with a Network and other plans that do not require joining a Network. As a general rule, there is usually a trade-off accepting insurance while in a Network and accepting insurance when not in a Network – that trade-off being that providers are usually paid less within a Network but also stand the chance of getting more patients via Network referrals.  There are other possible trade-offs such as being in a Network may mean filling-out more complex paperwork but often also means you know with more certainty just what you will be paid and you can get paid much faster.    

My advice about joining Networks and accepting insurance is really quite simple: If you are just starting-out or are trying to build a patient-load, why not join as many Networks as you can and accept as much insurance as you can? This will involve a lot of paperwork in the application process and learning how to follow different requirements for different Networks, but the only way you can really learn what makes sense for you is to try these systems out first-hand. If you are not seeing many patients, you should have the time to learn the ropes and this will be time well spent.   

By far, the largest Network of Acupuncturists in the U.S. with the most business is with American Specialty Health (ASH) – a company I have worked with since they first began to build managed care plans for AOM services about 15 years ago. I now serve on the Board of Directors of American Specialty Health Group – the company that manages these plans. Some 2,000 acupuncturists contract with ASH and they have a better than 90% retention rate with their Acupuncturists. I know more about ASH than any other Network but, again, I always advise to join several and find out for yourself how they work and which ones you want to continue with.

When working with these networks, you will have details available regarding what is covered and what is not and how much you will be paid and that is one of the advantages. One of the disadvantages of accepting insurance with a company that you do not contract with is trying to learn just what will be covered and how much you will be paid. This is what is called “verifying benefits” and it is the worst part of accepting insurance as different insurance plans have very different policies regarding acupuncture.  

While some insurance companies may tell you that you can verify benefits online, you almost always will need to do so by phone. You will want to get information on both “covered services” and “covered conditions” by calling the number of the patient’s insurance card. “Services” refers to the modalities you might use – acupuncture, cupping, tui-na, etc., while “conditions” refers to the type of health problems the insurance pays for.

When you call, tell them that you area service provider calling to verify benefits for one of their policy holders. They will ask you for (any combination of) the following information: The patient’s name, the policy holder’s name (your patient may be the spouse of the policy holder, for example), the patient’s date of birth, the policy holder’s employer, any policy numbers, and the social security number of the policy holder – which may also be called the subscriber’s I.D. number. They may then ask you for the provider’s (your) name, tax I.D. number and office location.

You then need to ask if the policy has coverage for acupuncture – by a Licensed Acupuncturist. You need to ask that because some policies will pay for acupuncture done by an M.D. but not by an acupuncturist! Don’t get me started. You next ask if there are any limitations on covered conditions. Most plans will cover pain conditions like back and knee pain and maybe headaches, but some plans have almost no limitations while others will only pay for things like nausea or even in lieu on anesthesia.  Again, don’t get me started.  You also need to find out about the patient’s deductibles and if it has been met as well as co-pay amounts. You should write this information down with the date you called and get the representative’s name so you have a record of what you were told.  

Unfortunately, even asking all these questions, the only way you can really learn for sure just what non-network plans will cover is when you bill and see how they pay. The thing is that acupuncture is such a tiny part of most insurance plans that their agents you call will not be that familiar with what is covered and they may not get that information clearly from their computer systems. You end-up learning by trial and error over time. Because of this, I advise that you send in your billing ASAP after the patient’s first treatment so you can learn how they will pay before doing too many treatments. You should also have your patient sign a form that states that they will agree to pay you in the event that their insurance company does not pay as they told you they would. You did your due diligence by calling and detailing what the representative told you but if insurance company does not end-up paying as they said they would, it is the patient’s responsibility to make good on it. They can then fight with their insurance company over the discrepancy if they choose.   

Well, this is about 1,200 words on this subject and I have only scratched the surface. There is more on this in my book and you can also read the series of Acupuncture Today articles I wrote on managed care starting with their very first issue.  Like many other subjects, I am ready and willing to take the time to offer detailed advice if there is a demand for it. Contact me through this Forum with your questions and don’t get discouraged. It just takes some additional training and I am ready to help you with all of this.

Matthew Bauer

Thank you for this!  Really great info, and I appreciate your help.

You are very welcome. Feel free to ask any questions you might have about insurance or anything else and please pass this resource along to your colleagues.

Matthew Bauer

Thank you, for this forum!  I am currently not taking insurance (graduated 1 yr ago) and I know that I am relocating to another city this July.  Do you recommend that I begin applying to insurance companies now?  Is it “simple” to just change addresses with the insurance company?  This is all very new to me, and I really want to “hit the ground running” when I arrive to my new city/home.  

Adrianne Ortega

Hi Adrianne and welcome! Happy to hear you are trying to plan for your move and hit the ground running. When it comes to insurance, things can vary from state to state as it is the state that regulates it but – for the most part – there are two different ways you will deal with insurance companies. One way is when you sign a contract and become part of their network of providers and the other is when you are not under contract and you produce some sort of bill for insurance reimbursement. One exception is in Washington State because they have a mandate to cover acupuncture and you have to be an enrolled Acupuncturists but they limit the number that can enroll. So – other than Washington State, you can look to become a network provider with different insurance companies and it would probably be wise to start the process before you move if you know your new address. The difficult thing is that the number of patients you will see that will be under any given type of insurance will vary a lot so it is not easy to try to get signed-up with the “best” ones because you just won’t know which ones will you will be seeing more of than others. You do want to get up to speed on how to bill those plans where you will not be under contract. I hope you had some training for that in school but I would be happy to help you understand how to do that if you have specific questions. My book has some overview on the difference in insurance health plans and then there is a second thread in this form for insurance billing (part 2).

Please let me know what state you will be in and if you have any more questions and I will help you to get more prepared for the move.

Matthew Bauer

I apologize for sounding so naive – I actually truly am. Is the first step to insurance getting a NPI number? I have not read the insurance chapter of your book yet. Do you recommend any other books that may walk me step by step through the process? I am & still will be in Texas. Can I use a residential address? I only ask because I do not know where I will be living until June. Can I use a friend/family address in my future city? I apologize for my ignorance this is why I am trying to get answers.

Adrianne Ortega

Hi Adrianne – you don’t have to apologize for not being well prepared coming out of school. That is the unfortunate norm and the reason why I am trying to help with my book and resources like this forum. I just ask people to use this forum so we can capture these types of exchanges so others with similar questions can learn from them also – so thank you for sharing here.

Yes – you should go ahead and apply for an NPI number using your current residential address. Once you relocate you can get your address changed online. It looks like they may start to require everyone to get a separate NPI number for the facility you work out of too but you can try to find that out once you move.

The Points for Profit book published by Blue Poppy Press has a good section on insurance billing. Too bad it is so expensive. One of that book’s three authors, Marilyn Allen, also works for the American Acupuncture Council and they put on seminars for insurance billing that qualify for PDA/CEU credits and you can learn a lot from that so you may want to check to see if they will be putting one on soon in your area. They are also a company that offers malpractice insurance for acupuncturists so you can contact them to find out about both of those things.

You may also be able to find help from you State acupuncture association. I am not familiar with what kind of resources the Texas association offers its members but the information you seek is exactly what a membership association SHOULD be offering its members.

Whatever you do to learn about insurance billing, I can help you here. It takes a while to wrap your head around the technical details but once you learn those it is not so difficult. It does take time for the initial learning curve but when you are just starting out and not very busy then you have time to learn on the job – not just about insurance billing but many aspects of both clinical and business matters. That is why I advise people to look seriously at opening your own practice so you can learn these important skills while you build a patient base. Once you build that base to a point that you have a reasonable, stable income and know the basics of how to manage a practice, then you have the freedom to decide where to go from there.  

Matthew Bauer

I will start with my NPI number and go from there.  Yes, I was thinking of that AAC seminar.  Most of them are far from me & none in Texas.  Not sure why???  I will have to catch one in New Mexico.  I will get my hands on the Blue Poppy book.  

One more question – about where to open a practice.  9 acupuncturists for 800,000 people sound ok?  I guess I would be the 10th.  Doable?  

Thanks again, for this forum & book!  So helpful!

Adrianne Ortega

Matthew Bauer

Hi Nancy  – Welcome to the Forum, thank you for the post, and you are welcome for the info!  As I always say, accepting insurance is a personal choice that each practitioner needs to investigate to see if doing so makes sense for their practice. What would make this investigation much easier is if your state acupuncture membership association did their job and have all this information available for you. Unfortunately, most associations do not have that info readily available for their members so that leaves most having to try to research this for themselves. If you go to sign a contract with any insurer or Network, they should have all the information about what they pay and for what services and for what covered conditions. You would then want to look that over and decide if it seems worthwhile to you. I get frustrated most acupuncturists and membership associations have not seen fit to do the work needed to gather and share this sort of information. Much of what I am trying to do here on this site including in this Forum, is to encourage this type sharing. I only wish more people would make use of this resource or get involved in their state association and see that this work gets done there.  As for the impact of the Affordable Care Act, it will likely take more time then the next few months to get an understanding of that and, like many things with insurance, it will vary from state to state. 

Matthew Bauer

I am an office manager for a Holistic center and the owners want me to look into getting the company start taking insurance. I have never done anything like this before and not sure where to start. I found your website and it is interesting reading. We have locations in different states, Illinois, Virginia and Maryland. How do I go about getting the information I would need?

Thanks. 

I assume your offices will be using different types of practitioners like Chiropractors, Acupuncturists, and maybe others? I am most familiar with acupuncture but let me give you the websites for two companies as I know the owners of each and they do a good job.  One is Acuclaims – a company that does both acupuncture and Chiropractic billing services and run by Mori West. The second is the American Acupuncture Council a company that runs insurance billing seminars for Acupuncturists across the country and is run my Marilyn Allen. Both the websites are below and both groups will be able to give you a lot of useful information. Please let me know how it goes and also if your company needs to hire any Acupuncturists!  

http://www.acuclaims.com/

http://www.aacinfonetwork.com/seminar_detail.php?seminar_name=All%20Seminars&sortby=start_date 

Matthew Bauer

Thank you for the information, much appreciated. We do Acupuncture, massages, yoga and nutrition. 

As a matter of fact we are looking for an Acupuncturist for our VA and MD office. 

You are welcome and please give me any information you can on the job openings and I will post it on my Facebook page. We have over 900 Friends there from all over the U.S. and some outside the U.S. You can do that here or send via email to me at acu.guy@verizon.net 

Matthew Bauer

Hi Matthew,

I need insurance guidance.  I am accepting out of network insurance and is going well so far.  I have found that there are a few policies that have pretty great coverage of acupuncture.  I am having issues getting in network.  Cigna has good coverage in my area, BUT every time I call I get the same response, “We are not looking to add an acupuncturist in network in your area.”  There is no one in the area that is in network and they will not let me bill out of network either.  I am not sure how that is legal – to offer benefits, but not make it available.  I am also having issues getting in network with BCBS and Humana.  I fill out forms via the internet and do not get a response.  Then when I call the companies to add me to in network I am told to fill out their info. form on the web.  I am not sure what I am doing wrong.  I have “plenty” (4-6 new patients a week) of cash patients, but I know I would have more patients if I was in network.  I want to be in network before the holidays this year because patients always “tighten their belts” and I now live in a blue collar city.  I would appreciate any guidance you have to offer.    

Thank you, 

Adrianne

Hi Adrianne – Thanks for your questions. Could you let me know what state you are in? Different states have different issues with their insurers so maybe we can find someone with experience in your state. I would say though that it might help if you had a patient who has insurance from one of those companies giving you the run around to contact them telling them they want you in their network. The thing is that the patient with the insurance policy has some rights and ability to raise a stink while you as a non-contracted service provider do not. The other possibility is that your state association may be able to help if you happen to be in a state with a functional association. Let me know what state you are in and if you know someone with a policy, ask if they will start raising a fuss to try to get some answers.  

Matthew Bauer

Ok, thank you, for the advice.  I am in Texas.  Thanks again!

Adrianne Ortega