Tag Archives: BlueCross

Unpaid Demands of Insurance Carriers

Unpaid Demands of Insurance Carriers

As someone who might have some insurance coverage that claims to “cover” acupuncture services, you might think that your provider is being reasonably compensated. In all but a minority of situations, “in-network” providers are paid very poorly. They are not paid for their expertise, for the time it takes to do a thorough diagnosis or evaluation, nor for the time they spend doing the treatment, for all the insurance verification and billing, for the accounting required, for their overhead, let alone anything left over for take-home.

Seriously, insurance plans and the third party administrators are making huge profits while providers are expected to go bankrupt for the sake of their patients and the insurance plans.

For example, start out with the contracts and policy manuals that the carriers and third party administrators expect providers to read, understand, and follow. Are they paid to review these? No. Are they paid to take the time to understand them? No. All of that is on their free time. No providers in the acupuncture world are on salary if they have to know all of this. And the number of acupuncturists on salary? Infinitesmaly few.

Unpaid Demands of Insurance Carriers

Here is a 4 page document listing only a small number of plans. This mailer is required reading for by providers.  It is just a drop in the bucket of the papers and documents that are supposed to be read by providers and their staff.

Please take the time to read it and understand it. How much time did it take you? How much should you be paid to have to do that? Please let me know.  Because providers get zip for doing so. And if they have staff, they have to pay them to take the time to read it.  Who pays for it?  Not the insurance company.

On the other hand, how much were the writers of this paid to create it? Mucho dinero. Believe me. It is the administrators, the JACO inspectors, the policy wonks, the CEOs who are making millions off of this. But the providers you rely on for help? NOTHING.

And the administrators will blame it all on regulations. Regulations that they created to obfuscate and then blame providers for not following.

Unpaid Demands of Insurance Carriers

And I bet that your insurance premiums are going up astronomically. My personal Kaiser policy is going up 21% this coming year. Is there any corresponding increase in fees paid for treatments done? Ha Ha Ha. The jokes on you if you think that independent providers get an extra cent from the increase.

No, the joke’s on the providers who accept the plan payments. Like The Redwood Clinic. SUCKERS!!!

Is there any increase for even increases in costs? Rather, the fees continue to be cut with more and more demands to do more for free.

Unpaid Demands of Insurance Carriers

Insurance carriers and third party administrators are laughing all the way to the bank. And providers are dropping like flies. That is why there are so few providers accepting insurance. MDs, unless they are part of a medical group associated with a hospital/insurance plan complex.

The truth is, those providers lucky enough to get a job with such a medical group/hospital complex are a rarity in the alternative medicine field. The jobs are rare, and the insiders are all referring their friends to get the insider-employee referral fees. There is no hiring based on experience, it is just new-age nepotism. Speaking from experience. Age discrimination is rampant in this system apparently as well. The MDs I spoke to 2 – 3 years ago were all retiring because the system was starving them out of business. Years of clinical experience are a noose on a resume.

Unpaid Demands of Insurance Carriers

How many plans are there? Unknown, but here is a single sheet of paper distributed that is supposed to be memorized by providers. Hilarious if it weren’t so obviously clear proof that the system is broken.

One online insurance billing and verification system list 7370 insurance payors. Seven Thousand Three Hundred Seventy. What if you personally had to know which to chose to get YOUR salary from? Crazy. No, insane. But that is the system. This list is just the first 50.

The fact is that suggesting any of the above, no matter how based in fact, puts a mark on my chest, a target on my back. Was this the reason I was taken off a Kaiser referral list, in spite of the fact that I was being paid 30% – 100% less than other contracted providers? This was sex discrimmination. And would Kaiser and any of the six executives there answer any questions I sent by certified mail about the reasons for the termination? No way.

Which is sad to me because I have provided excellent service to patients there for years. Numerous patients were very upset that they couldn’t get continued care with me and Kaiser refused to explain to me or them the reasons. They wrote letters on my behalf and Kaiser officials and employees refused to provide any response.

I have also been a member of Kaiser myself for years. Paying huge premiums that have paid for the salaries of executives and middle managers in the Outside Referrals Deparment. What do you think? Should I change to another plan during this time to change Covered California Plans?  Why did the following executives of Kaiser NEVER bother to respond to my letters? Pragya Wagle, Nicole Lipes, John Loftus MD, Deborah Gould MD, Lawrence Hamilton, Anita Zuniga RN, Millicent Brown Hunter RN.

“PEOPLE ABOVE PROFITS” is supposed to be the motto of Kaiser Permanente.  The actions of the leadership are wholly inconsistent with this philosophy in the way they have disregarded a very loyal consultant of 20 years.

 Tags: Pragya Wagle, Nicole Lipes, John Loftus MD, Deborah Gould MD, Lawrence Hamilton, Anita Zuniga RN, Millicent Brown Hunter RN.

Acupuncture Benefits Insurance Coverage


Acupuncture Benefits Insurance Coverage

[Editor’s Note: While Positivity is the Usual Tone for this blog, this article is addressing a more serious trend and so is not upbeat]

Typical Medical Insurance Policy restrictions regarding Acupuncture Benefit and Reimbursement

You are all excited that you found out your insurance plan has acupuncture coverage. You think, “wow, it says I am entitled to 12 visits a year. Or 20 visits a year.” And you are thinking “I am entitled to getting each and every one of them and it is the doctor’s duty to do that for me.”
You are also perhaps feeling that the providers on the list are super happy that they get to work with you because you have insurance.

Well, providers are usually happy to be able to help you with their skills and art. That is for sure.
But in many cases, for the provider, the insurance part of it is not the warm and fuzzy feeling you have.

Why would that be? Please continue reading to the end to better understand why.

When you are not paying their usual and customary fees, in other words, if you are not paying full cash rate out of pocket, there are some things you should seriously consider to make the professional relationship work.

Acupuncture Benefits Insurance CoverageThe elephant in the room, your insurance plan, will always have either a good or bad effect. So it is incumbent upon you to understand the system that is the intermediary in this business transaction.

Think about it. You go in to buy groceries. You pick up what you want. You go to the cashier. You pay out of pocket and you get the groceries. Did the store have to bill a third party to get paid?

Or you go to a financial planner for advice. You go in, you pay in cash, check, credit card, etc., you sit down and talk. You get the advice. You pay then and the financial planner gets paid then. No insurance involved as a middle man.

Let’s say you work at a coffee place. You are a barista. You get paid hourly or as a salary. People come in, order, pay (maybe sometimes with a discount card or coupon), you make what they want, they leave with what they bought. No insurance involved in the middle of that transaction. And you don’t have to bill some intermediary, like and insurance company, to get your pay check.

But that isn’t the way it is for the solo or group medical professional who has agreed to help patients by accepting their medical insurance. It is a totally different situation. You should understand it, especially if you want a good relationship with your provider and if you are thinking of going into that profession as well.

<h2>Acupuncture Benefits Insurance Coverage Basics</h2>

You have a contract (medical insurance) that says the insurance company will pay for some of your treatments in particular situations. This is called a “benefit.” “Benefits” are always limited in scope.

Eligibility means that you can access your plan because you (or someone else) paid your policy premium, so the medical insurance contract is in effect.

You have asked your possible provider to accept insurance payments. Typically that means that you want the provider to be satisfied with the amount that you pay with your copay and the part that the insurance company pays in addition.

So the provider (or paid staff) has to spend time and money to find out two things first. Your eligibility. And if you are eligible, do you have the (examination, evaluation, treatment) benefit?

Now, even if you are eligible and have, say, acupuncture, benefits, that doesn’t mean that your condition is one that the insurance plan agrees can be helped or treated with acupuncture.
This is an area of confusion for most patients.

Once again, just because you have the benefit it doesn’t guarantee that the provider will be paid. It doesn’t mean that the benefit applies to your condition. ALL INSURANCE PLANS specify what types of conditions they think might be impacted by acupuncture, herbs, shiatsu, massage, cupping etc.

MOST plans restrict “relevancy” to certain musculoskeletal problems, chroinic pain, nausea with pregnancy, and perhaps a few other diagnostic categories.

When the provider treats you, he has to provide diagnostic codes on the bill. He has to provide procedure codes. These two together relate to whether the benefit will be paid or not. If the insurance plan decides that they don’t want to pay for a particular benefit because they don’t like that diagnostic code, the provider will not be paid by the insurance company.

And don’t ask the provider to lie about the diagnosis just so you don’t have to pay.  That is jeopardizing the provider’s license.

The provider if under contract, might then be able to send you the bill because they can bill you for anything the insurance plan won’t pay for. Other times, the insurance plan will tell the provider “tough luck. We won’t pay you and you can’t bill the patient.”

How fair is that? Not fair at all, I would propose.

Especially, when the time and cost of dealing with insurance plans is so severe for providers.
1. They have to spend time verifying eligibility and benefits. That could take as much as 1 hour or more. And then there still is no guarantee that the information will be correct.
2. They have to spend time making appointments, corresponding with the patients, actually examining and treating the patients, collecting co-payments, and then billing the insurance company for the balance.
3. Automation hasn’t really made much of a difference in this time issue, especially when the insurance company denies payment.
4. Knowing how to deal with the insurance system itself is a MAJOR expenditure of time and money. The insurance companies don’t ever pay providers for this time required to learn the system and keep up on all of the alerts and newsletters related to changes in the system and contracts.
5. On top of it all, insurance companies, with a few exceptions, have slashed reimbursement rates to participating providers. In most cases it is a 50 -90% reduction in their fee schedule.
6. And then there is the paperwork requirements imposed. Of course, again, no compensation for any of that given to the provider.

How are Acuncturists Paid:   Independent providers aren’t given a salary. They aren’t provided an hourly wage. They have overhead and business expenses that they have to pay before they can take payment for their own expertise and work out of the small amount of money the insurance company gives them for their professional expertise.

 It is likely that your insurance doesn’t even cover the cost of overhead if your doctor bills the insurance company directly.  Some insurances do, most don’t.

Please keep this in mind when you call and ask a provider to make an appointment with you when you have a PPO plan. If the tables were turned, is it you who is doing the favor or the provider doing you the favor?

Granted, there are a few insurance plans that are not stealing from the providers. But there are many more plans that claim that they pay for the treatment, but don’t.  In fact, often the patient pays way more in a copay than the insurance company itself pays.

And YOUR plan might be one of those.  Hopefully, not.  But if it is, extra consideration for your provider might just be just what the doctor ordered.