I admit that I have not been as involved in the healthcare debate as I would like to be. People are unsatisfied and I'm not surprised. I'm not going to complain and expect that writing about it will make any changes for the better. My views would probably be simply stated, without much research to validate my arguments. Being new to the profession as a Licensed Acupuncturist, all I know is I've lost money this year to the insurance game, for many reasons. Most people don't know what their plan entails. This is a problem, and I'd like to help you solve it.
One FAQ is "Do you accept insurance?" and this is not directly a yes or no question, with the potential to make one feel foolish if it's followed up with "What kind?" and you stutter to say "I don't know." If you are a patient who wants to find out if it's possible to receive benefits for acupuncture or any alternative healthcare services, a better question would be phrased as "Do you accept [insert insurance company name here]?" You pay hundreds of dollars on your premium yearly so at least try to know who the money is going to. I personally think you should carry your insurance card at all times for these instances, but that's just me.
So, you've asked the doctor if they take your insurance. They say they are In-Network. This is good, but not a done deal. The next step is to call your insurance company to see if you are eligible for this type of benefit. This is the patient's responsibility but if you ask nicely, I'm sure with enough information (Date of birth, ID #, Group #, Customer Service phone # found on the back of the card) the office staff will call for you. The downside is that if you wait until your appointment to check, there's the chance it's not covered or you need an MD's referral and you drove down there for nothing. Frustrating situation #1.
Just because a provider is In-Network and can perform the service does not mean you have verified eligibility. Every insurance plan is different and you get what you pay for. If you have insurance through your employer, they may have certain restrictions that you cannot change, noted in the policy. Many companies don't cover alternative therapies but if the customer calls to inquire about this, they may realize that several affinity programs are available to you and can give you a significant discount (10-25% off the regular rates). If you mention this to a participating In-Network Provider, they are required in their contract with the company to offer this and no paperwork needs to be done.
If you know that you can receive acupuncture benefits, the next step is to ask the insurance company how much your copay is per office visit and acupuncture treatment. These are two different procedures, with two different codes that the office uses on the claim. During the initial intake, a physical exam and health history can take up to 1.5 hours, which is categorized as an office visit, whereas the acupuncture treatment is separate. Even if it occurs on the same day, some insurance companies want you to pay two copays. Frustrating situation #2.
It's also important to know if there is a limit on the number of acupuncture treatments you can receive per calendar year. Sometimes the magic number is 12, which is generally one treatment plan in my office (once a week for three months). Other plans may allow you to get acupuncture as long as you don't go over a certain amount of $ out-of-pocket over the course of the year (i.e. $1000). Some plans only cover specific diagnosis codes like pain or nausea from chemotherapy or pregnancy. If your insurance plan expires, it's always wise to let the office copy the card of the current plan you are using.
If your practitioner is Out-of-Network but you know that your insurance covers the procedure, there is the option to be reimbursed after you have paid for the services. Keep in mind that they most likely will not cover the full amount paid, but it definitely helps. In most cases, your provider can file this claim for you with your signature on file.
Claims may take up to a month to process and in some instances need to be appealed...it's quite inconvenient to stop treatment when you are 1/3 of the way through because of some confusion about paying for the services. As a practitioner, this may cause tension with the patient, which I try to resolve by offering my discount in the meantime. There are times when the patient is committed to getting results and they take advantage of the opportunity. Other times, they sacrifice receiving proper care because they have chosen to stick within the limits of their insurance. I can understand this, but I also find that the suffering is prolonged, which is unfortunate. It's best to prevent this situation by having knowledge about your insurance before starting treatment.
I hope this information has been helpful for you to understand the relationship between the healthcare provider, patient and insurance company. I have encountered many flaws in the system such as patients and providers speaking to different departments with false information, insurance companies unable to find my contract or fee schedule on file, a patient neglecting to check their benefits, and failure to receive a referral from their primary care physician before the office visit. Save yourself time and a headache and inquire about your options. You might think they don't cover alternative medicine but you may be surprised!