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Archive for the ‘Insurance and Acupuncture’ Category

As a specialty of Acupuncture, Aetna actually has NO acupuncturist network in Virginia (VA), Washington DC area.

Aetna only has one acupuncture discount rate network through ASH, i.e. American Specialty Health Acupuncture network. So, it means any acupuncturist has to accept a discount fee schedule if he/she join the ASH network when treating a patient who has Aetna insurance.

But, sometime, if the patient has Aetna Acupuncture benefit, Aetna may pay the acupuncture provider at a out-of-network fee schedule (see, save money) –i.e., according to the rule, Aetna should have an acupuncturist network (but has NONE), then Aetna could pay the provider treating its HMO/EPO patient, –Aetna may refuse to pay, because no acupuncturist is in-network. Sometime Aetna may pay the treatment for PPO patients who have acupuncture benefit (as an out-of network, 50%-70%, patient need pay more, such as high deductible due to out-of-network, high percentage of coinsurance, 30-50%), which Aetna may also refuse to pay…….the reasons—medical unnecessary, or acupuncture benefit only for acupuncture anesthesia—that means it should be done when surgery by is done by an MD—not by an acupuncturist.

Aetna insurance is not very clear about the acupuncture network issues, acupuncture benefit definition, HMO, EPO, PPO, etc. , and payment.

Appeal? No one will say that “my processing was wrong” in Aetna insurance office. The representatives seem to always have many reasons to refuse any appeal.

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Today, one of my patients asked me–Dr. Fan, You are the Provider in My BlueCross BlueShield Insurance Network, Why I have to Pay Acupuncture Treatments?

Here is the answer:

Only when the patient has acupuncture coverage will the patient’s insurance “may” pay the acupuncture fee for patient. Why do I say “may” pay for?

It depends on a few conditions:

(1) If patient has an HMO, even if the patient does have acupuncture coverage, but the provider is not an in-network provider, the patient has to pay by himself/herself;

(2) If patient has PPO (with acupuncture coverage), and without limitation in deductible and illness condition, the provider also is an in-network provider, then insurance company should pay for the patient’s acupuncture treatment.

Should the patient have a PPO but without an acupuncture benefit, the patient will have to pay out of pocket. But the insurance may advise the provider to give such patients some extent discount/or just pay a reduced fee;

If the patient’s PPO has an acupuncture benefit, but has some pre-conditions, such as acupuncture treating the low back pain only, the patient will have to pay for acupuncture treating other conditions, such as upper back pain, neck pain, etc. If the patient has deductible, say, $500, or $1000, even acupuncture is covered, the deductible part has to be met first (paid for by patient prior to PPO paying).

And the co-pay (such as $25 or $40) or coinsurance part (such as 10%, 20% of the “allowed amount”, etc.) is the patient’s responsibility.

(3) Another issue is: insurance may cover acupuncture or electric-acupuncture only, other related therapies, such as Cupping, Tuina, Infrared, etc., in the theory, should be paid by patient. However, sometime, the provider may give patient a courtesy–at no additional fee.

Sometime, the flexible spending account could help patient to cover the part of self-pay, save patient’s tax in healthcare part.

Another very important issue is that if the patient has acupuncture benefit, most of the insurance companies define that acupuncture is only for chronic pain management, but some insurance plans are  for “acupuncture anesthesia” (which means only during surgery—actually this is a “joke” in the USA as there is not any licensed acupuncturist doing acupuncture anesthesia—the insurance company gives you a benefit which does not exist at all).

So, for acupuncture treating infertility, depression, etc. (without the pain), insurance will not pay for that.

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There are NO direct answer.

The amount of deductible, copayment and co-insurance part are various very much, it depends on your specific plan.  So, you could call your insurance plan to find them acurately.  Of course, some insurance companies provide online check-up service, so you could see it online and print it.

Deductible is your self-pay part before your insurance starts to pay; Copayment is the part you pay each time at the provider’s office (such as $10-30) when you visit them; Co-insurance part is the percentage insurance set for your responsibility.

For exemple, if the patient has $400 at deductible part, $20 for copay and 20% for co-insurance, that means–when he or she starts to see an licensed acupuncturist (in-network), patient should pay $400 first before insurance could start to pay (the first evaluation and treatment, second treatment……untile meet $400 patient self-pay; but if the patient already saw another provider, met some portion of deductible, he or she will pay less than $400). In the first evaluation session, patient also needs to pay $20 copay, but not for treatments. When insurance starts to pay, patient also needs to pay the 20% part at the insurance fee schedule (not the provider charged amount).

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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.

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