FAQ: “Why Don’t You Accept Insurance?”
This is the first entry of a few upcoming “frequently asked questions” blog posts! There are some questions I am asked often enough (or that have a long enough answer!) that I wanted to take the time to explain in a place that is easy to find. Starting with a bang, in this entry, I will explain why I don’t accept health insurance and what alternatives are available to you to save money on your treatments. This applies specifically to health insurance, but many of the answers can be applied to auto insurance and/or workers comp insurance - though they have their own specifics as well.
In this entry, I cover:
Setting the Scene: quickly covering the basics behind insurance terminology and what’s needed to have coverage for acupuncture;
“Why don’t you accept insurance?”: describes the nitty-gritty information of insurance coverage step-by-step;
“What are my alternatives?”: lists the ways available to save a bit of money on your treatments;
Behind the Scenes: gives you a glimpse of how this applies specifically to my practice (and many other acupuncture practices), including how some of the math shakes out (or, in this case, doesn’t).
Setting the Scene
Let’s start with some background on insurance as it relates to acupuncture. A few aspects are involved in having any service covered by health insurance: insurance plans, diagnosis codes, and billable treatments.
First, you need to have a health insurance plan that covers acupuncture.
If your plan does cover acupuncture, then your insurance company will have specific diagnosis codes that they accept acupuncture treatment; this means they will cover acupuncture as a treatment for specific ailments (such as low back pain) and not others (like headaches).
Finally, your insurance company determines the length of time that is considered “billable,” meaning how much time the provider will be paid for and how much they will pay for each billable period of time. For acupuncture, this is typically in 15-minute increments, with a maximum of two increments per patient (or 30 minutes). The reimbursement rate is typically between $15-25 per increment.
With that info in mind, let’s get back to the question:
“Why don’t you accept insurance?”
The most straightforward answer is that chances are high that your insurance company does not cover acupuncture, so I can’t bill your insurance company. But, you know I like details, so here is the longer answer too.
Insurance companies based in Iowa do not offer coverage for acupuncture. Blue Cross Blue Shield Iowa/Wellmark makes up about 80% of the insurance market here in Iowa, and they do not cover acupuncture. Cigna, another major insurer, doesn’t cover it either.
Medicare only covers acupuncture for low back pain when provided by a physician who is also a licensed acupuncturist. (More info on that here.)
The VA does cover acupuncture, but you typically have to receive care internally (or on-site). You can learn more about that here.
So, if there is no coverage, it is not an option for me to accept insurance! However, some people have health insurance plans from out of state that may offer coverage. For example, some other states' Blue Cross Blue Shield plans do cover acupuncture. The only way to know if you have coverage is to check! You can check online or call your insurance company to verify what your plan covers. So, why don’t I bill out-of-state insurance companies?
If your insurance company does cover acupuncture, it will only be for specific diagnostic codes. Treatment for low back pain is often covered by insurance. However, things like headaches, insomnia, or digestive concerns typically aren’t. Occasionally, nausea is covered when it relates to pregnancy or chemotherapy. HealthPartners, a Minnesota company, covers acupuncture for things like fibromyalgia, PMS, and migraines. Coverage all depends on your plan and the state where the company is located.
To bill an insurance company directly, I need to be “in-network” or credentialed with them. This is an application process with the insurance company, and you’re not always approved! It's unlikely an out-of-state insurance company would credential me. I would need to “credential” with each insurance company that someone would like to bill. This involves signing a contract with the insurance company agreeing to various policies, such as their reimbursement rate.
If I were credentialed, I would need to seek payment directly from the insurance company. There are several reasons this won’t work: I run a micro-business, and I am a one-person show without a receptionist or additional staff. I rely on being paid the rate I set to run my business. Insurance companies typically reimburse $35-55 per visit. Additionally, they don’t cover additional hands-on treatments, such as cupping or massage. To make that financially viable, I would need to increase the number of patients I see per hour to at least 2, likely more. (This is why your doctor sees patients every 10-15 minutes or less!) In addition, payments from insurance companies can take time to process, which isn’t sustainable at a lower volume clinic. (More on this below.)
I don’t think health care should be this way, but unfortunately, it is our current system. I truly keep my pricing as low as possible while remaining sustainable for both my business and me! My patients regularly tell me that being able to spend 60-90 minutes with me during their appointments is really valuable for them!
“What are my alternatives?”
There are two main alternatives to billing insurance directly for care. They are:
Using an FSA or HSA card. This option is available to everyone! You can elect to put pre-tax money into your FSA/HSA card, which can then be used for acupuncture appointments throughout the year. You can also purchase packages of appointments with these cards.
Submit a Superbill to your insurance company for reimbursement. This “out-of-network” option is for people who do have coverage for acupuncture in their plan. I can create a receipt, called a Superbill, for your care that you can submit to your insurance company. Superbills contain the diagnostic codes for the conditions we treated during your visit, and the company will then evaluate whether or not the care you receive matches your coverage. If it does, they will reimburse you the amount they pay for out-of-network acupuncture providers. While you likely will not get 100% of the cost of your appointment reimbursed, you can often get around 50% of the appointment cost back. To be clear, Superbills are not a guarantee of reimbursement, but it is an option that is worth a try! If this is something you’d like to discuss more, let me know at your next appointment or email me.
If neither of those options is a good fit, you can purchase packages of appointments, which provide about a 10% discount and are designed for people who visit the clinic 1-2 times per month. I also offer memberships, which are a good deal for people with 2+ appointments each month.
Finally, I understand that in-office acupuncture treatments aren’t always affordable for people! In this case, I also offer affordable online classes and events, as well as free information on the blog and resource pages (such as qi gong, meditation, food therapy, recipes, and more - check the top navigation bar to see all the options!). Remember, Chinese medicine isn’t just acupuncture! You can learn the theory and many of the techniques and apply it at home, too. If you need help designing your best home-care practice, you can try the Coaching appointments; these are virtual appointments, and we meet less frequently.
Behind-the-Scenes Information
Here is a bit of a behind-the-scenes look at why accepting insurance, even if it was an option in Iowa, is not sustainable for my business:
As I mentioned in the beginning, insurance companies choose how much time they will pay a provider. Insurance companies can also choose how much they want to pay the provider, regardless of what the provider charges. When a provider signs up as an “in-network” provider for an insurance company, they agree to accept the amount the insurance company provides and can’t bill the patient for the remaining amount. This is great for the consumer but can be difficult for a provider!
Let’s do the math:
My 60-minute follow-up acupuncture-only appointments are $85. An insurance company will pay me $35-50 for that appointment instead. The remaining $50-35 that the insurance company isn’t paying has to be written off, and the provider just won’t be paid that amount.
Let’s say I did some bodywork during the 60-minute appointment, like cupping or massage. That is a $115 appointment. The insurance company would still pay the same $35-50 for that appointment because they don’t cover bodywork. So, in this case, I would be short $50-80, or I would need to charge out-of-pocket for that service.
While it may seem obvious to some, it’s important to remember that the $85+ per appointment isn’t going straight into my pocket! Business expenses - including licensing fees, continuing education, rent, supplies, and more - all need to be covered by the appointment fee I charge!
In high-volume settings or clinics where people are seen quickly, it is possible to absorb the lost income through sheer numbers - this is what you experience with most doctor’s offices. Acupuncture clinics accepting insurance often see patients every 15 minutes! This means a lot less face-to-face time with patients. The number one piece of feedback I receive from patients is that they appreciate how much time we can spend together during their appointments. This just wouldn’t be possible if I were billing insurance!
Additionally, there is the administrative cost of billing insurance. As you might imagine, billing insurance companies can be time-consuming, and clinics that bill insurance often have someone on staff whose job is to manage that process. Additionally, insurance companies can take weeks to pay practitioners, which can be difficult in smaller clinics.
Finally, something not often known by patients is that insurance companies can audit patient files for three years after appointments. During these audits, insurance companies could decide retroactively that the treatment already provided and paid for didn’t meet their requirements, and the clinic (that’s me!) could be required to pay the insurance company back. This is a massive liability for a business owner!
Wrap Up
So, as you can see, billing insurance is a complicated process! The process is often unfair to their customers (that’s you!) and the providers. I think we can all agree that the insurance companies are the winners in these scenarios! So, I navigate this mess the best I can to be fair to you and to keep my business open.
I am always open to adjusting treatment frequency to match your budget, and we can brainstorm the best way to continue your treatment with home practices. Don’t hesitate to use the free resources on my website - they are the same information I share with patients in the clinic!
I hope this answered all the questions you had about insurance coverage (and probably a few you didn’t think of!) - feel free to email me if you have any other questions or if you have ideas for another FAQ you’d like me to cover in the blog.
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