Most patients continue to approach the TCM physician, or Licensed Acupuncturist and herbalist, with the question of whether they accept their insurance. My practice accepts any insurance that will pay, and the question is whether that insurance will pay for the treatment, not whether I will accept payment. There is a long history of complex practices to deny payment for medical services performed by this medical specialty, despite its low cost and now proven effectiveness. The hundreds of plans offered by insurance companies, the yearly changing of plans at your business, and the lack of effective regulation of straightforward business dealings has made this a needlessly stressful situation for patients that are suffering a health problem, and almost all countries now utilize some form of single payor policy to relieve this patient stress and facilitate efficiency in healthcare. Both federal and state legislators have been trying to forward laws that would mandate the free individual choice to get treatment from a licensed physician such as myself for decades, but lobbying efforts have effectively stymied this free choice, and most patients are now unaware of whether their insurance plan actually covers this care, or how much is covered by their plan. The Healthcare Affordability Act of the Obama administration has achieved much to help with patient access to the TCM physician, or Licensed Acupuncturist, encouraging state run medical insurance exchanges to include coverage for this specialty, and working toward instituting outcomes-based payment systems that will encourage integration of effective low-cost Complementary Medicine in the future to achieve better outcomes at a reasonable price. For now, we still have to deal with a confusing and complex insurance system, though.

Simply put, this physician accepts any insurance that will pay the bills, and if that coverage is limited to a small amount per treatment, a professional superbill can be provided to more easily obtain this limited reimbursement after the patient chooses to pay a greatly reduced out-of-pocket fee. If there is a sizable unmet deductible in the plan, or lack of coverage for acupuncture services, many patients now take advantage of one of 3 types of health spending plans that provide tax benefits or employee benefits to pay for this deductible out-of-pocket spending, and for professional Complementary Medicine in general. These plans, the Flex Spending Account (FSA), the Health Savings Account (HSA), and the Health Reimbursement Account (HRA), are uniform tax-advantaged health spending accounts mandated by federal law that relieve much of the financial burden of the individual in paying for the services of the Licensed Acupuncturist and herbalist. The array of different health plans and networks, with more and more complicated rules and details, though, is now extensive, and it is best if the patient proactively calls the benefits number and checks on coverage, network requirements, deductibles, and limitations, such as the number of treatments allowed per year, or a maximum paid for acupuncture on their policy per treatment, or per year. Since my practice is very small and my time is spent in delivering time-intensive therapy, it is helpful for the patient to check on insurance details before seeing me, and I greatly appreciate this effort. Insurance companies have not been helpful in providing clarity of information, and this can be frustrating, both for the patient, and the physician. Hopefully, by individually checking benefits on your plan, one day these insurance companies may be forced to simplify the process, and the policies, rather than continue to complicate it. This practice of complication in health plans has resulted in most medical clinics having to spend an inordinate amount of money to simply deal with insurance, raising all of our insurance premiums and taxes.

What you need to check when you call your insurance company, or benefits representative at work, to confirm coverage is:

  1. whether your particular plan has coverage for the Licensed Acupuncturist,
  2. whether the acupuncturist must belong to a network agreement, or whether there is also out-of-network coverage,
  3. whether Paul Reller is in the network,
  4. whether there is a deductible that is not met for the year (in which case, you must pay out of pocket until this deductible is met),
  5. whether there are limitations applied to coverage, such as a limited number of treatments per year (sometimes lumped with any chiropractic therapy that you also may get), limitations on the percentage that is paid on acceptable treatment codes, or limitations on what diagnoses are covered with acupuncture therapy.

The copayment amount is usually listed on the insurance card. Actual confirmation of benefits, though, are not confirmed until the company sends a check with the explanation of benefits (EOB). The acupuncturist has no control over any denials or limitations of payment, which is a contract between the patient and the insurance company. Ultimately, if there is a denial or limitation of benefit payments, you may need to appeal this decision, and my office will facilitate any problems, which are rare, and minimize out-of-pocket expense if you are ultimately liable.

Advantages of supporting the private practice in acupuncture

Most patients are only concerned about how much they must pay out of pocket for their healthcare, but the smart patients are beginning to understand that the insurance and health industry has many bad practices that drive up the cost of their insurance policies, and their is little trust left between the patient and the big business of healthcare. Supporting the private practice insures that the standard of corrupt billing practices to increase income are not supported by the patient. For instance, even acupuncture is now being adopted by large healthcare corporations, and the pressure is on to force the physicians who practice acupuncture into contracting with large companies instead of maintaining a private practice. The treatments in hospitals and affiliated “wellness centers" are more readily covered under related health plans, but the billing practices in these facilities are not scrutinized by patients, and often, these billings are not following the standard medical fee schedule, with excessive charges and reimbursements being made to increase profits within the company. The acupuncturists themselves are usually under a fee contract, and not responsible for billing amounts or improper fees and codes, and the salaries are usually low. In many cases, the Licensed Acupuncturist makes a salary reflecting as little as ten dollars per treatment, yet the healthcare company may bill up to 600 dollars per treatment. With little oversight, corrupt billing practices and complicated fee reductions have resulted in much higher medical fees and profits. Who pays for these now common practices of overbilling, false billing codes, and illegally inflated fees? We do, the patients who pay a yearly increase in their insurance costs of nearly 10 percent. Healthcare reform still has not addressed the now common practice of billing manipulation.

While the understandable focus of patients is on minimizing the out-of-pocket costs with rising insurance premiums, attention to the bigger picture may result in a better deal in the long run. Contracted and independent Licensed Acupuncturists adhere to standard fee schedules and low cost healthcare, and usually provide a quality of treatment that may not be seen in the acupuncture provided in hospitals, standard medical clinics, and “wellness centers". In these corporate environments, the salaried Licensed Acupuncturists, and the physicians who practice acupuncture with little formal training, are usually restricted regarding the type of care, and the amount of time they can spend with each patient. Often, acupuncture is authorized for only a few types of medical conditions, and the practice of restricting even which points are to be needled is not uncommon. The standard TCM practice of combining professional herbal and nutrient medicine, and the physiotherapies of Tui na, are usually not allowed. By supporting the Licensed Acupuncturists in private practice, the public will insure that integrity in billing practices, and integrity in the quality of care, is maintained. Patients may obtain copies of their bills from these corporate affiliated clinics to see exactly how much is charged for each treatment against their healthcare policy. Today, attention to these business practices, and attention to the quality of care, by the patient, is most important.

Managed care and the requirements of a doctor's referral

There are two types of insurance plan that require a primary doctor's referral before beginning treatment with the Licensed Acupuncturist, plans restricted to a Medical Provider Group (MPG) where an M.D. is assigned that oversees all care, and a Point of Service (POS) plan with Managed Choice (MC). The first type of plan, an HMO (health managed organization) with an MPG will assign a physician within the medical provider group to manage all care and refer patients to specialists. Either way, the insurer rarely informs the patient/customer of how these plans actually work, and a little knowledge goes a long way. Making sure that the plan rules are understood and followed before getting treated insures that the treatment will be covered properly. A stitch in time saves nine, as my Grandma used to say.

Many of these HMOs, or most, do not yet allow a Licensed Acupuncturist to be a member of the provider group, or may have a small number of Licensed Acupuncturists on site in a hospital facility, or have medical doctors that have some minimal training to perform acupuncture on site at a clinic. To receive real care from a Licensed Acupuncturist in private practice, pre-authorization should be obtained. This is a simple procedure if done correctly. Obtain a note from the assigned MD that simply states that in his or her opinion acupuncture care is medically necessary to treat a specific condition, and that a certain number of treatments are recommended. Take this recommendation (not a simple referral on a prescription pad), and call the number on your insurance card, requesting contact with the pre-authorization department. After contacting pre-authorization, fax (or mail) the statement of medical necessity from your primary doctor to this department, and follow-up to confirm pre-authorization. A written document confirming this is preferrable. Bring the pre-authorization to this office to include with the billing.

If your insurance plan is a POS (point of service) plan, requiring a medical referral from your assigned network M.D., you usually have the choice of getting this referral, which entitles you to a higher percent of your medical costs being paid by the insurer, if the Licensed Acupuncturist is in the network, or you may go to a physician of your choice, such as the Licensed Acupuncturist, without a referral, out of network, and have just a small percentage of the treatment cost paid.