Acupuncture and Chiropractic Insurance Billing & Practice Management

Too many providers are more concerned with the SIZE of their office than anything else.  They immediately share space with another provider because his office is so large or has so many treatment rooms.  However, they rarely stop to think about why the provider is offering to share the space.  Is it because he can’t fill it himself?  Or pay for it himself?  Did he pick a bad location?  Is he using you to help pay his bills?

I’ve seen plenty of highly successful practitioners make a very good living in a very small space.  I call these “boutique” offices, and some are like little jewel boxes.  They offer things the big offices can’t or don’t.  Because they have less overhead, they can adequately space out their appointments and spend quality time with each patient.  Every small office I’ve ever been in has the tea on, and I’m always personally greeted.  I usually don’t wait long, but they know I’m there the second I walk through the door. I don’t care if they have just two treatment rooms and not ten, and I’m not alone in feeling this way; a patient wants a personal experience, and that usually comes in a smaller environment.

Patients also want convenience over the size of an office.  Who cares that you are renting space in a big fancy office if you aren’t available the days and times I’m available to see you?  Or what if I can’t get parking, or if I can, but it costs me?  When making a decision about your office probably the size should be low on the list of considerations.  Don’t let ego get in the way.  Think about the experience of the patient.  Literally how is he going to think or feel from the moment he gets there until the moment he leaves?  Less is more.  You actually can charge more in a small office; it’s about the time you spend and the concern you show; it’s not about the size.  It never has been.

Clearly, one becomes an acupuncturist because he/she is a caring individual who wants to be part of a healing experience for others, rather than a number cruncher or pencil pusher.  Consequently, most acupuncturists would fall under the “right brain” category.  That’s the side of feelings rather than logic, more philosophy and religion than math and science.  Because of this most practitioners have a difficult time embracing that left side, and some will say, “That’s why I got into acupuncture because I don’t like business.”

Sadly, you may go out of business if you shun all aspects of business.  Accordingly those providers who realize that they are in business and as such must have a clear understanding of the various aspects of business tend to be more successful and therefore get to treat more patients and be a part of that experience they wanted in the first place.

So where should you start if you realize you really need to exercise that side of your brain?  Here are 5 top tips:

1.  Start by keeping track of your numbers.  How many patients did you see today?  This week?  This month?  How much money did you make today?  This week?  This month?  There are many programs out there that will easily keep track of the figures for you.  Just get used to looking at the numbers.  Don’t just keep track of your cash; your insurance patients, too.

2.  Expand your reading.  It doesn’t have to be the Wall Street Journal, but how about an article in the business section of the paper?  Most daily papers have one day when they highlight small business.  Find out what day that is and read at least one article.

3.  Don’t use your checkbook as your accounting system.  Programs like Quickbooks offer Simple Start- Free Edition.  Get used to entering in your information and looking at your data and budgeting.

4.  Take advantage of the government.  There are many free and low-cost classes and seminars for small businesses.  Both the SBA as well as the SBDC (Small Business Development Centers) offer local classes.  The SBA also has many online classes as well.

5.  Network with other businesses.  It’s all about relationships.  Not only is it possible for you to get referrals but you can learn something from others in business.  Join a breakfast club, chamber of commerce or referral organization.  Being with successful business owners will help you think in kind.

The end result of all of this is you need to stay in business to treat your patients.  To be the best healer you can be you have to keep your doors open.  You can’t follow your passion if you aren’t making a profit.

Even acupuncturists with experience billing insurance get confused about how to handle the claims for a patient that has Blue Cross/Blue Shield.  In most states, the Blues are combined; only about four have separated the two.  The thing that seems to cause the most problems is where to call for benefits and where to submit the claims.

You always use the number on the patient’s ID card to call for benefits.  You are calling that person’s insurance company, also known as the home plan.  However, when asked where to submit the claim the insurance carrier will tell you to submit to “your local.”  “Your local” is the Blue Cross/Blue Shield in your particular state.  So easy enough – call the home plan to get benefits, and send the claims to your local plan, also known as the “host” plan.

The plot thickens when you receive an incorrectly processed EOB (explanation of benefits).  The check and EOB will come from your local, and this is where you call to explain that your claims were not processed properly.  They, however, will tell you that your claim was “priced” at the home plan, and that the direction to pay or not to pay came from the home plan.  Confusion is now setting in; who are you supposed to call if you cannot contact the home plan for claims issues, only benefits?

If you are not on top of it you will play a back and forth game of calling the host plan who will promise to contact the home plan and get the claim reprocessed.  You must therefore document every contact you have about this claim.  After two attempts to contact the home plan you should escalate the issue and have the host plan send an email to the home plan for clarification.  Stay on the phone while that email is being sent and received.  Wait for an immediate answer.  Once a host plan rep speaks to a home plan rep you usually can get the issue resolved.  Document the name of the representative you spoke to, the reference number for the call if one is available and how long it will take to get the check.

What if you are in California, where there is both a Blue Cross and a Blue Shield, and you are told to send to the local?  Well, 90% of the time the local will be Blue Cross; but if you are not sure then send to both; one will make it to the right place.

Fourteen years after the original HIPAA Act (The Health Insurance Portability and Accountability Act) went into effect offices are still not clear about some requirements. A lot of offices still believe that you cannot have a sign in sheet sitting out for patients to sign as it is against confidentiality requirements. I’ve seen offices where right after the patient signs the sign in sheet, the front office person immediately takes a giant sharpie to effectively block that name from view. What was the actual point of signing in in the first place? What I also find funny is a lot of times that very same front office person will ask a patient about his/her condition, or medication right in front of others in the waiting room.

Other offices use a two-part form, so the patient signs on the top part that is perforated and the office tears off each line after signing, however the signature is caught on the bottom sheet. Other offices use a sheet of file folder labels; after signature, the label is then removed and placed on another sheet kept out of view. A lot of work, and the bottom line is: nice but not necessary.

It is perfectly acceptable to have your patients sign the old fashioned sign in sheet as confirmation they have arrived for their appointment. However that is it. A lot of offices add a “reason for your visit” box next to the name. THAT’s the part you can’t do. Ask the patient to provide that kind of information and now you’ve created a HIPAA violation.

The very same office that is such a stickler about the sign in sheet will, for the convenience of the staff, have multiple computer screens that are plainly visible with patient information for all to view; other offices will print the doctor’s appointments with names and diagnosis for each day and post those on the doors of the treatment rooms, which are both HIPAA violations.

Bottom line: use good common sense, and you can keep your sign in sheet. (337)

Weekly I receive questions asking why an insurance company didn’t pay a claim, or didn’t pay enough.  Providers insist that they “should have been paid” for a procedure; it is in their scope of practice so therefore it MUST be covered.  Unfortunately the insurance industry is not set up that way.  What is and isn’t covered in written in the patient’s benefits manual also known as the Summary Plan Description, or SPD.  The SPD will spell out exactly what is covered and is literally considered the bible for interpreting a patient’s benefits.    NOW, the in network provider will already know what procedures are covered as they have a contract with the carrier, however they still need the SPD to know which diagnosis’ are covered.  The out of network provider must rely on the SPD to know what will be paid.  So the obvious question would be – How do I get the SPD and read the information about acupuncture coverage?

First, understand that NO carrier is going to give that to you.  You are a third party and therefore they have no authorization to request an SPD.  The patient does and should in fact be given an SPD when he signed up for coverage.  He should also be notified and given a copy when any changes are made to his benefits.  So ideally your patient should have one. (Yes, I know I said ideally.)

Also ideally it is best that before treating a patient and billing his insurance an office should always call and verify benefits  however this is not without it’s limitations.  You will be dealing with a representative who is reading off a screen and the information being read may not be the actual SPD, but rather a cheat sheet or shortened version.  In most cases you can get fairly accurate information but not always the complete coverage.  Insist that the rep read it to you – many times they want to give you their interpretation of the coverage.  I always say – please read me exactly what is written word for word.  Usually one can find that acupuncture treatment for a certain diagnosis WILL be covered however however in many cases the rep  will not be able to confirm nor deny that the E/M codes nor various modalities will be processed and paid.  At that point to be sure one would need to see the actual SPD, or send to a department called pre-determination or pre-authorization.  This department of the carrier will match up the request for treatment with the SPD and give the final word on coverage.  Unfortunately this process can literally take weeks with some carriers so it is not done too often.  When in doubt I advise out of network providers to collect from the patient and wait for the EOB to be sure. 

Finally there is an actual federal government department that is devoted to making sure carriers follow the SPDs.  Next blog will have information about that department and how to use them to make sure a patient’s benefits are being processed correctly.

If you are out of network with United or Aetna you are familar with the Multiplan fax – This is where they offer you a quicker payment for a reduction of payment.  Of course the answer is always – NO THANKS.  The problem is getting out of the system.  Reps will tell you that they HAVE to offer you the discount each time you submit a claim.  I have contacted the VP of Marketing for Multiplan who told me this is NOT true.  You can be removed from their system and stop receiving their “offers”.  The best way is to put it in writing, on letterhead and fax back to them.  For the record – NEVER ignore their fax, always respond – writing with a sharpie across  with the words – We do NOT accept and fax back as soon as possible.  You can also call.  If you don’t respond, they don’t assume you don’t accept, rather your claim sits in limbo.  So respond quickly.  Then write that letter and get out- FOR GOOD.

We have been successful in removing practioners from the system.  Try it, and if you continue to receive the faxes and the phone calls, email me and I will personally help make it stop.