We would first like to apologize for any confusion, frustration, or miscommunication regarding insurance coverage. My team and I have been accepting insurance in our clinic for over ten years, and we understand how confusing it can be to navigate medical health insurance. Please understand that we do everything we can to ensure the claims we submit on your behalf are paid, and this time-consuming process can take 90 days or more.
Please continue to read as this article will explain how your claims are processed and how practitioners are viewed by your insurance company. We will cover:
- Insurance Verifications
- Copays, Coinsurances, and Deductibles
- Patient Account Balances
- Office Visit/Evaluation/Assessment, Acupuncture, and Diagnosis
- Insurance Claims Denial
- Prior Authorizations
Insurance Verifications
We provide insurance verifications at no cost to patients or prospective patients in an effort to be transparent about your responsibility. However, an insurance verification is never a guarantee of payment from your insurance company. Insurance verifications are standard practice within the acupuncture community because of the varying types and levels of coverage.
We do our best to ensure payment and collect from your insurance company. We also do our best to modify and correct insurance claims to obtain payment from your insurance company, and this process takes time.
Copays, Coinsurances, Deductibles
This may be one of the most confusing areas of medical insurance. Any insurance policy can have a combination of deductibles, copayments, or coinsurances, and we do our best to clarify each of these when we verify your insurance benefits. However, we have seen a dramatic increase in insurance companies informing us that deductibles “do not apply” when we verify your insurance, but then applying the deductible when we submit the claim for payment. The responsibility of this incorrect information lies directly with your insurance company.
Another discrepancy we have discovered is an increase in insurance companies informing us that patients only have either a copayment or coinsurance during the verification process, but at the time the claim is processed, the insurance company is stating that the patient owes BOTH a copayment and coinsurance. We make every effort to be transparent with our patients, so these discrepancies are extremely distressing for us as your provider because we expect the information provided by your insurance company during the verification process to be accurate.
Sadly, we do not have any power or authority to change what the insurance company pays us nor the amounts they state are the patient’s responsibility. We are under contract with your insurance company, and we are obligated to collect amounts that are labeled as patient responsibility.
Patient Account Balances
Copays, coinsurance, and deductibles are due at the time of service. Patients are required to put a credit card on file so that we can charge your card accordingly. Once your claim is processed, we will automatically charge your card on file for any balance due that was not collected at the time of service. This charge will match your explanation of benefits from your insurance company. If you think you have overpaid, please reach out to Lisa Whistleman in our billing department at lisa@dc-acupuncture.com.
Office Visit/Evaluation/Assessment
Acupuncture sessions will be billed with an initial evaluation at your first visit and reevaluations at regular intervals – usually every 6-8 visits, if there is a change in diagnosis, or if you have not been seen for at least a month.
Evaluations and reevaluations are required to assess your condition, determine the appropriate course of care, develop treatment plans, and are part of best medical practices. Patient evaluations are a foundational part of patient care, standard billing practice, our office policy, and cannot be changed or opted out of.
Patient responsibility is determined by your insurance. We do not have any power or authority to change what the insurance company pays us nor the amounts they state are the patient’s responsibility. We are under contract with your insurance company, and we are obligated to collect amounts determined to be patient responsibility. It is possible that your insurance will apply higher patient responsibility when we bill these evaluation codes.
Acupuncture Billing and Diagnosis
There are several pieces of information we submit on insurance claims that are used to determine coverage and payment. Two of the most important pieces of information are a billing code and diagnosis code.
One major discrepancy we have discovered is that insurance companies are informing patients that their office visit/evaluation/assessment is included in the acupuncture billing code – This information is incorrect and needs to be reported to the District of Columbia Office of the Commissioner. The billing codes, known as Current Procedural Terminology (CPT) codes, are owned and defined by the American Medical Association, and acupuncture billing codes ONLY cover the procedure of acupuncture.
Another major area of insurance claim denial happens because of the diagnosis. Most insurance companies will only cover diagnosis codes associated with pain management and nausea associated with pregnancy or chemotherapy. This short list of codes are:
- headaches (R51.9 Headache, unspecified)
- migraines (G43-G44 Migraine with and without aura)
- neck pain (M54.2 Cervicalgia)
- low back pain (M54.50 Low back pain)
- nausea during pregnancy (O21. 9 Vomiting of pregnancy)
- nausea during chemotherapy (R11)
We do our best to work with you to ensure payment from your insurance company for treatment, and this means navigating the insurance system and possibly co-treating you for multiple conditions.
Insurance Claim Denials
Unfortunately, we do not have any power or sway over how your insurance company processes your claims. We submit insurance claims based on standards set by our profession, the ethics of our profession, and our contractual obligation with your insurance company. We are noticing an increase in insurance claims denials as well as higher amounts being marked as patient responsibility.
We have had several insurance companies inform patients that we are submitting insurance claims incorrectly and that the claims should be resubmitted. This is incorrect because we submit claims within industry standards, and our professional advisors and billing team have extensive experience in the medical insurance billing realm. With a few exceptions, this increase in claim denials is the sole responsibility of your insurance company.
The largest area of denials we have discovered happens when an insurance company provides us with incorrect information during the verification process. Our insurance verification team is extremely thorough, and they make every effort to account for commonly known claim denial rationales. However, as mentioned above, we have no control over the information an insurance company provides our team during the verification process, what they reimburse, and the amount stated as the patient’s responsibility.
Prior Authorizations
Some insurance plans may require prior authorization. We should be informed at the time of insurance verification whether a prior authorization is required. Our billing team will obtain prior authorizations when needed. In some cases, we may not know whether or not one is needed until after a patient’s initial evaluation. In the event your insurance company fails to inform us of this requirement or denies a prior authorization, you will be responsible for the cost of treatment.
About the Author
As a practitioner and healer in Washington, DC for more than a decade, I take a patient-centered approach to care through acupuncture, cupping, herbal medicines, and mind-body coaching, with a specialty in full-spectrum reproductive health care.
