Every insurance company, even same insurance but different plan, pays acupuncture treatments very differently. Some paid more than $100 per session, some around $90, some around $70, some only $25 –even lower than the copayment for other treatments, for example, for Physical Therapy in some cases.
The fee schedule in some insurance companies are based on their surveies, they may set a fee schedule – 80% of average level of last year. i.e. if the average charge of acupuncture treatments in last year was $110, then their fee schedule would be $88 in this year. The CareFirst BlueCross BlueShield likes this. However, a few other insurances pay at so-called negotiating price, for example, if the provider charges $110, they may negotiate with the provider at 75% of the billing price, so their payment will be around $80.
Of course, another factor affects the insurance payment to the providers is patients’ premium paid to insurance company each month. If you paid low, the fee supposed to pay to the providers by patients’ insurance should be lower, and patients may also need pay higher deductible, higher copay, and even some percentage of the fee to the provider.
Actually, insurance company pays acupuncture according to how many small sessions in a whole session. So, you could see each whole session may include in two or three different CPT code-97810,97811 or 97813, 97814 depending on how complicated the treatments(how many problems the acupuncturists handled in a whole session).
Another factor is the way of representatives processing the claims, based on the understanding the policy in different way, they may process the same claim very differently. So you may see the different results, when different representative process the same claim–it occured in some insurance plans.
Do not be over-stressed with the balance between the insurance payment and the provider’s charge. In most cases, you do not need to pay it—if this provider is a in-net-work provider, that means he/she accepts that insurnce agreement-do not charge the balance to patient. However, the patient should pay the deductible part, copayment and the fee for other than the acupuncture, for example, herbs.
In the theory, the providers should charge the fee for cupping, tuina(therapeutic massage), etc. But sometime, they do not–just for a coutesy treatment–if insurance does not cover it.