The Basics > Insurance > 1) Personal Health Insurance
Health Insurance can be confusing for both patients, physicians, and office staff. . Hopefully the information below will help you understand the most important aspects of health insurance.
This page includes the following sections:
INSURANCE VERIFICATION FORM: My Insurance Verification Form is on my "Office Forms" link. If you would like to discuss your insurance options with you, please print out and fill out that form first. As you will see, it will require you to make an initial call to your Insurance provider.
This page includes the following sections:
- General Info
- My Network Relationships
- In-Network Provider - Explained
- Out-of-Network Provider - Explained
- Choosing In-Network vs Out-of-Network Providers
INSURANCE VERIFICATION FORM: My Insurance Verification Form is on my "Office Forms" link. If you would like to discuss your insurance options with you, please print out and fill out that form first. As you will see, it will require you to make an initial call to your Insurance provider.
1) General Info
- Your Plan's Benefits Dictate Coverage -- Personal Health Insurance may or may not cover Acupuncture. It is a function of your plan's benefits. Just because one person with Blue Cross has coverage has no bearing on the next person.
- Number of Visits -- Plans that do cover Acupuncture typically have an annual limit on number of visits ranging from 12 to 25. Often times Acupuncture visits and Chiropractic visits are grouped together for a total visit maximum.
- Pre-authorization by Primary Care Physician -- In most situations pre-authorization from a primary care Physician is NOT required, but some plan's do require that.
- Pre-authorization by Acupuncturist -- In most situations pre-authorization from the treating Acupuncturist is NOT required, but some plan's do require that. That is an odd situation as you will need to come in for an evaluation for the service provider to gain the information needed for the treatment, but you will not be able to get a confirmation any Acupuncture treatment would be covered until after an authorization is received back from your Insurance company.
- Types of Conditions Covered -- In most situations there is no limit on the types of symptoms and conditions that can be treated and covered, but some plan's to have strict limitations. (Aspire, for example will only treat for physical pain conditions and nausea not due to pregnancy. So they would no cover treatment related to a digestion or thyroid issue, for example).
- Patient Costs/Practitioner Reimbursement for In-Network Patients -- Reimbursement is based on the type of service provide (regular acupuncture or electric), and the length of time the practitioner is with the patient and the number of needle sets used. The system as it relates to the needle sets is not really in line with most day to day applications of Acupuncture, but it is what it is... The contract rates an Acupuncturist will get paid for a visit are NOT known until after the first Explanation of Benefits are received. Insurance companies do NOT provide reimbursement pricing to Practitioners without a filed claim (believe it or not). An acupuncturist who spends very little face time with a patient and puts in one set of needles could expect an in-network reimbursement of $30-40 per treatment. (which means a patient who gets services from the same should expect a max out of pocket cost of $30-40 if a deductible applies and it has not been met). An acupuncturist who spends moderate time with a patient could expect to see $40-50 per treatment, and someone who spends more time may see $50-65.
2) My Network Relationships
If you have health insurance, no matter what kind (PPO, 80/20, a plan that requires copays) you must become familiar with the terms "in-network provider" and "out-of-network provider".
I am an in-network provider for many of the local and state level specialty insurance companies related to teachers and/or labor unions. I am NOT in network for Blue Shield as of the end of 2016.
I am an in-network provider with (so I am an in-network provider for):
I am an in-network provider for many of the local and state level specialty insurance companies related to teachers and/or labor unions. I am NOT in network for Blue Shield as of the end of 2016.
I am an in-network provider with (so I am an in-network provider for):
- Aspire Health
- Cigna PPO
- Blue Cross -- Some plans, not all.
- Some of the local school and union insurance plans
- Blue Cross - Some plans
- Blue Shield
- All other insurance companies...
3) In-Network Provider - Explained
An "in-network provider" is a physician who has made the effort to sign up to provide services for your insurance company. When a physician signs up to be "in-network" he/she benefits because he/she is listed in a directory that you, as a patient and insurance subscriber have access to for "in network providers" (aka "preferred providers"). It's like getting a listing in the yellow pages. However to get this listing, providers must agree to pricing that is often times below their list price for services, and ironically, they can't/won't tell you what they pay for services when you sign up! It's a real head scratcher. When you go to an in-network provider, they should:
- Provide services
- Collect co-pays at time of service (if they are known and/or can be properly figured out)
- Bill your insurance company their retail rate, and then wait for an Explanation of Benefits (an "EOB") response from your insurance company (typically a 10-14 day turn around).
- The EOB will dictate what the contracted rate is for the services you were provided and how much of that contracted rate is going to be paid by the Insurer for the Date of Service in question. The amount they are going to pay for a particular Date of Service is based on the current amount of money paid against your deductible.
- After processing the EOB and any associated checks, the Physician will bill the customer directly for the balance of the amount due and he/she is limited to billing no more than the contracted rate that was specified by the insurer on the EOB.
4) Out-of-Network Provider - Explained
An "out of network" provider is ANY physician. Yes ANY physician can/is an out of network provider. That physician is NOT bound to contractual rates set by any insurers. Almost all health insurance policies will allow you to go to an "out of network" provider, they simply give you much less credit against your deductible and/or reimburse much less for the services as compared to if you went to an "in network provider". When you go to an "out-of-network provider", they should:
- Provide services
- Collect payment in full at time of services
- Provide you with a specific type of receipt ( a "Super Bill") that allows you to file your insurance visit with your insurance company. Thus the visit will go against your deductible (but not at retail value of the services), and/or you may get a check back from your insurance company for a portion of the services if your deductible has been met.
5) Choosing In-Network vs Out-of-Network Providers
The first question you want to ask a new physician is "Do you take insurance"? If the answer is yes, ALWAYS follow that up with "I have xxx insurance. Are you in-network or out of network?". They should know quickly if they are in or out of network, but sometimes it's not as simple as it should be.
In some cases the health care provider will ask for your Insurance info and birthday and check the status for you. That's the older way of doing that. We don't do that anymore. If bad information is provided and you provide services and that bad information comes back to bite you, you look like the bad guy. Often times they will give you a reference number for the call so you can protect yourself in a case like that, but the time involved in rectifying that is a nightmare and the damage may already have been done to your image with the patient.
We have shifted to providing a written script to the patient and putting the onice on them to call their insurance company to find out if we are in or out of network and what their benefits are. This also engages them in the insurance process and it ultimately is what you need as a small practitioner to keep things in balance if you are going to take insurance.
Q: Is there ever a time to go to an out-of-network provider when there are in-network providers in the same geographic area?
A: Absolutely. Finding a good care-giver/wellness professional or physician you can work with is similar to finding a mate and/or a partner. Providers and patients are partners in the healing process. If you can find an in-network provider that works, you will receive maximum financial benefits, BUT if you can't find someone who is getting the job done as well as you'd like, accept the decreased benefits and find someone that's able/willing to help you achieve your goals.
In some cases the health care provider will ask for your Insurance info and birthday and check the status for you. That's the older way of doing that. We don't do that anymore. If bad information is provided and you provide services and that bad information comes back to bite you, you look like the bad guy. Often times they will give you a reference number for the call so you can protect yourself in a case like that, but the time involved in rectifying that is a nightmare and the damage may already have been done to your image with the patient.
We have shifted to providing a written script to the patient and putting the onice on them to call their insurance company to find out if we are in or out of network and what their benefits are. This also engages them in the insurance process and it ultimately is what you need as a small practitioner to keep things in balance if you are going to take insurance.
Q: Is there ever a time to go to an out-of-network provider when there are in-network providers in the same geographic area?
A: Absolutely. Finding a good care-giver/wellness professional or physician you can work with is similar to finding a mate and/or a partner. Providers and patients are partners in the healing process. If you can find an in-network provider that works, you will receive maximum financial benefits, BUT if you can't find someone who is getting the job done as well as you'd like, accept the decreased benefits and find someone that's able/willing to help you achieve your goals.