Tag Archives: EHB

Insurance and Acupuncture 2015- The State of the Profession

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Many Acupuncturists hold that increasing insurance coverage is necessary for our professional future. It’s a main goal of the NGAOM. HR 3849 is the same legislation the AAAOM has lobbied for in the past. The Acupuncture and Oriental Medicine Society of Massachusetts is working on legislation mandating insurance coverage, and a similar bill has been introduced in Vermont. A handful of states include acupuncture in their ACA plans.

I don’t believe Acupuncturists have to sell their soul to participate with insurance, and I don’t believe insurance companies are evil.

I do believe many practitioners haven’t considered the overall impact of insurance coverage on their business, the profession, and the medicine.

Participating with insurance invites a third-party into the treatment room. The Acupuncturist (or any Care Provider), the Patient, and the Payer share one goal – that the Patient feel better as quickly as possible. Beyond that, there’s plenty they don’t share, including – how to define treatment success and fair compensation. How many and what type of treatments are necessary. What provider types to reimburse. How best to control health care spending. How to provide care for those with expensive medical conditions. How to assess quality care.

Patients and providers often see the payer (a faceless bureaucracy that isn’t in the treatment room) as the bad guy. But the payer’s business depends upon watching every penny, and always trying to get more for less. Payers often say no (or that’s too much) to patients and providers.

In the past year, conversations about insurance coverage have included:

  • Practitioners about to open their first practice with no idea where to begin.
  • Copies of statements from an Acupuncturist who bills insurance $2,000 per treatment.
  • A practitioner insisting that billing a Manual Therapy code for point location is legit.
  • Many responses of “everyone has pain somewhere, so bill for that” to questions about codes for a specific condition.
  • Discussions of how to use CPT codes so that reimbursement amount equals desired amount.
  • Concerns about audits.
  • Concern regarding reductions in reimbursement rates.
  • Complaints that panels are closed (the insurance company won’t accept additional practitioners in-network).
  • Reports that companies are requiring current NCCAOM credentials for participating providers, even when not required for state licensure.
  • Anger when offers of expedited payments for reduced amounts are offered.
  • Complaints about time spent resolving billing or reimbursement errors.
  • Questions about proper policies around co-payments and co-insurance.
  • Discussions of how to serve the patient who has not yet met their deductible.
  • Concerns about retaining patients who have reached their treatment limit.
  • Stated goals of treating patients with limited resources, without recognition that those patients often have limited coverage.

We’re inviting a powerful bureaucracy into our practices, one with the power to define our medicine in the eyes of the public. Other professions have strong and responsive support systems to balance the power of that bureaucracy. We don’t. Are we prepared for the continuing effort that will be necessary to protect our interests? We play this game at our peril.

 

 

Assistance for the Working Acupuncturist

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I went down the Facebook rabbit-hole, and while I was there I learned a few things.

For instance, “just a quick look” and “I’ll just scan my notifications” can quickly lead to a month without a blog post. I will not let that happen again.

Also, based on posts about HIPAA, insurance billing, choosing office space, maintaining records, etc., we have  a lot of questions and we are looking for answers. It’s great that we’ve got communities of colleagues to ask. It is also inefficient, and sometimes downright dangerous that our colleagues are often the only source of answers.

Looking at HIPAA and ADA for example, we see that some professions (but not acupuncturists) have access to lots of resources from their national associations.

  • a search of the AAAOM site gets one, not very useful hit, regarding HIPAA-related responsibilities.
  • Here’s information from the APTA (American Physical Therapy Association) site on HIPAA.
  • Here are the search results for HIPAA over at the American Chiropractic Association.
  • I can find no information on the AAAOM site about acupuncture offices and ADA compliance.
  • APTA provides these useful links about ADA compliance.
  • The American Psychological Association has great information about ADA compliance.

While acupuncture organizations are working on national legislation, increasing insurance coverage for acupuncture, adding an entry level degree, and fighting with other professions to limit the use of the acupuncture needle, we search for authoritative assistance on current practice issues in vain. (Luckily, the links above are pertinent to our practices.)

To make matters worse, sometimes it seems that we prefer ignorance. In my time on Facebook I was reprimanded for self-promotion when I shared useful links to this blog, and I was threatened with banishment from Acupuncturists on Facebook because I “acted like [I] know it all.” (I don’t know it all. I do know a few things.)

When many of us don’t understand or comply with our obligations under the ADA and HIPAA, are we ready to be a part of the Medicare system or have acupuncture be an EHB? Isn’t accurate information about ADA compliance an important part of our stated goal of having acupuncture accessible to all? It’s past time for our schools and organizations to make sure we have the skills, knowledge, resources and information to be successful practitioners now. The FPD, Medicare inclusion, higher standards, and expanding our scope/suing our competitors should wait.

2013 Review for Acupuncture Professionals

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As 2013 was dawning, the WhiteHouse.gov petition to include acupuncture in Medicare was circulated by the AAAOM, NCCAOM, and loads of school and practitioners. Because coverage is not determined by the executive branch, over 30,000 signatures made no difference. That our professional organizations either didn’t know enough or didn’t care enough to educate acupuncturists about how the system works did give me the final push to create The Acupuncture Observer. From the first post last January through # 49 today, I’ve tried to provide thought-provoking strategic analysis of where we are and where we are headed.

The planned March AAAOM conference on a cruise ship didn’t set sail, making 2013 the second consecutive year without a conference. Things began looking up with April’s announcement that experienced professional Denise Graham was named AAAOM Executive Director.

However, by mid December, Ms. Graham and three Board members had resigned. (Previous ED, Christian Ellis, managed only three months in the fall of 2010.) A majority of the current board members have been appointed rather than elected. Something at the AAAOM smells. The Whistleblower Protection Policy, prepared in conjunction with the Confidentiality Policy adopted in April 2012, never resurfaced after it was pulled by then President Michael Jabbour (who is now managing the “operational transition”). We’ll probably never learn what is really going on in the board room, but 2013 marks the year I gave up hope that the AAAOM could become a viable organization serving the profession. It’s now become a single-interest (Federal legislation) organization, under the control of a small number of people, and without the resources to accomplish its priorities.

Throughout 2013 qualified LAcs were denied licensure by the Delaware Acupuncture Advisory Council’s insistence on the NCCAOM OM credential. New Florida regulations will limit licensure to those with NCCAOM Herb credentials beginning in October 2014, putting another state off limits to many practitioners and greatly increasing educational costs and the regulatory burden for those who intend to practice in those jurisdictions.

Outrage at  P.T. Dry Needling continued throughout the year. Some LAcs made arguments that reflect poorly on our concern for the public, such as suggesting we’d drop our objections if PT’s agree to use hypodermic needles for this technique. Various state associations began efforts to redefine acupuncture and to push for discriminatory insurance policies in response to dry needling and the end of 2013 brought newcomer NCASI (and their lawsuit against Kinetacore) onto the scene.

Late Summer brought proposed policy changes from the NCCAOM that would move the group several steps closer to becoming a regulating rather than credentialing body. In a bit of good news, comments from the profession sent the proposals back to the drawing board.

Over the course of the year growing numbers of practitioners added insurance billing to their practices.  We’ve been quick to throw stones at the billing practices (or rumored practices) of PT’s, yet many acupuncturists offer justifications for questionable practices and few seem clear on the exact nature of their agreements with the insurance companies.

In the waning days of 2013 a job opening for a Licensed Acupuncturist at Brooke Army Medical Center was posted on Facebook. Initial responses cast an interesting light on our profession’s self-regard. There were complaints that the salary (about 70k) was too low, some suggested that a PT would certainly get the job, and others complained about the requirement for a flu shot.

In a few days I’ll be back and begin looking forward. What will serve us in the year of the Wood Horse? When the dragon brings the energy of the spring back to earth, how should the seeds of the profession grow?

Acupuncture & Insurance, Part 2 — Affordability

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Many of us see it as a no-brainer. We want acupuncture to be affordable, insurance/Medicare makes it affordable, how could anyone be against that? This reasoning relies upon a superficial understanding of health care costs and affordability.

Consider:

  • Affordability must take into account premiums as well as co-pays and out-of-pocket expenses.
  • Both cost to the individual and sustainability of the system are part of affordability.
  • All medical costs are ultimately borne by the public.
  • When coverage is provided for the very sick, the premiums of many healthy people contribute to their medical expenses.
  • If health care spending exceeds what the insurance companies have planned for, premiums will go up and reimbursements for providers will go down.
  • Controlling health care spending depends upon providers accepting reduced payment for their services and upon a bureaucracy determining what services are appropriate.
  • The wealthiest in our system typically have the best insurance coverage.

A respected colleague said I give the impression that Community Acupuncture is the only way for people to get affordable acupuncture and that everyone should treat that way. My bad — I don’t believe that. I do believe it is a good way — it accepts the reality that acupuncture isn’t really more affordable if it doesn’t cost the system less. It provides affordable treatment to everyone, not just to those with the best insurance coverage. And it keeps big business out of treatment decisions.

I continue to treat one client at a time, in a private room. I have a generous sliding scale, available to all, to help a wide range of people afford acupuncture.  Some practitioners treat in private rooms and charge one low price to all patients. I have colleagues who reserve a certain percentage of their appointments for those who need steeply discounted services, and I have others who volunteer in free or low-cost clinics. These are all ways to make acupuncture affordable.

Disguising the cost of acupuncture by hiding the expense in co-pays and premiums (many so expensive that they are subsidized by taxpayers) doesn’t make it more affordable. Changing the way you treat so that your reimbursements match what you think you deserve doesn’t make acupuncture more affordable (or support arguments for cost effectiveness).

CA is not the only way to make acupuncture affordable and I certainly don’t think it is the only style of treatment that should be available.  But insurance increases the big picture affordability of acupuncture only to the extent that it limits reimbursement rates and access.  Insurance is not a magic wand, and those practitioners who believe it is are in for a rude surprise.

For more, check out this post, and these statistics about the increases in health care spending in the US.

Health Insurance for the LAc — Important Point #1

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Insurance does not create money, it redistributes it. The money coming in via premiums or taxes must be equal to or greater than the payments for services and the expense of the bureaucracy (whether government or private) that manages the system. (With government programs we have chosen to ignore the imbalance between what is coming in and what goes out. Eventually, we’ll have to face it.)

The system depends on lots of healthy people paying in more than they get back in services. That offsets the folks who need lots and lots of care.

Here are some costs (yes, this term can mean a lot of different things):

  • Type 2 Diabetes — Annual Medical expenses of $13,700 with $7,900 attributed to diabetes.
  • High Blood Pressure — costs of $733/person in 2010.
  • Stroke — Average cost for first 90 days after a stroke is $15,000.
  • Breast Cancer — Average annual cost of $22,000 to manage the early stages with management of stages 3 and 4 costs in excess of $120,000.

Some of the ways insurance companies made sure they took in more than they paid out:

  • limited the amount paid out over a lifetime — reach a million and you are on your own.
  • refused to cover pre-existing conditions — your diabetes will cost a lot, so we won’t cover it.  (This also kept people from waiting until they were sick to buy coverage.)
  • charged “sick” people significantly higher premiums — you have diabetes and HTN likely to cost $1000/month, so your premiums will be $1300/month.

Most of us were bothered by these limitations (especially when we think of individuals – your patient, your cousin). The PPACA eliminates or greatly limits these practices — you can’t be denied coverage for pre-existing conditions, there are no lifetime limits for EHB, and premiums are determined by age and type of coverage, not medical status. These changes force the companies to pay out more per person, and limits what they can take in per person.

To keep premiums from being unaffordably high many healthy people need to pay into the system. This is why the PPACA requires everyone to buy insurance or to pay a penalty.  It is also why the system collapses if everyone expects to get services equivalent to (or greater than) what they pay in premiums.

If someone pays a $150 monthly premium and expects to get ten acupuncture treatments/year, and you “deserve” $700 or more for those treatments, there isn’t much left to cover the bureaucracy or the costs of their neighbor with cancer, their father who just had a stroke, or their own colonoscopy, broken arm, or appendectomy.

This has real implications for your acupuncture practice — whether or not you are a participating provider, whether or not acupuncture is an EHB in your state, and whether or not you expect the AAAOM’s federal legislation to succeed.  Stay tuned for more.

(Here is an NYT article looking at medical choices and costs.)