American Acupuncture Council Important Updates for American Speciality Health

Hi, this is Sam Collins, your coding and billing
expert for acupuncture, specifically the American acupuncture council information network as
well as seminars and of course your malpractice carrier. Today’s program is going to focus
again on being in or out of network, but it’s more of an update to kind of keep you up to
speed as to what’s occurring. There’s recently been some changes for American specialty health
related to California, now New Jersey and then also some updates for the VA as to who’s
handling the VA. So let’s get started. Let’s go to the slides and let’s talk about just
being in or out of network. Hang on, I’ve got to make sure I can switch. There we go.
So for managed care, of course, that’s what we mean being in network. It’s a trade off
and so you can see here that, of course, it’s the plans offering. You get more patients
but you get reduced reimbursement. And the one thing I’ll always focus on or
have you focus on is when you join, whether or not there’s a value to being a member of
the plan. And we’ll talk specifically about these [inaudible 00:01:44] plans in just a
moment but always remember to keep it simple. If the plan is exclusive, there’s a high likelihood
you may want to join because otherwise the patient has no benefits with you whatsoever.
Now of course they can still pay cASH but very unlikely to seek care because they’re
going to go where they can use their insurance. However, what if the pay is not reasonable,
and this is the hard part I think most acupuncturists have, particularly with plans like ASH. It
is hard to manage a patient where you have to deal with insurance for a rate that is
below what you actually would even charge a cASH patient. Let’s remember, often you’re charging a cASH
or a prompt pay patient less than what you would charge an insurance patient. Not by
much, but less because there’s lesser paperwork, lesser administration, and so therefore it’s
hard to manage. When you’ve got these managed care that requires so much more information
and they require the extra work for lesser pay. So you do have to look if it’s exclusive,
but the pay is not reasonable, they’re very likely not to join. With an American specialty
health plan you’re talking to a 40 to $50 reimbursement, kind of hard to make an office
function, particularly if you’re in a high rent area. However, what if the plan is not
exclusive, meaning they can go in or out of network? Well, my opinion, why would you join
something where the patient has a choice to go out of network just as well. By example,
there are plans with United Healthcare and OptumHealth that actually paying more money
to out of network providers than in network. Often people are joining different groups
through to join Cigna and Cigna has a much better benefit out of network, so it’s certainly
something to look at to decide whether or not to join and really look at is the payment
reasonable, but also is it exclusive and or if the pay is low, do they send you a lot
more patients? That volume can make up the difference. But once you have to think of
is take a look towards the bottom here. You’ll say office costs to treat a patient. If your
overhead is say $4,000 a month. As you can see in this example, and you see about a hundred
patient visits a week or 25 per week, or excuse me, a hundred patient visits per month and
25 per week, that means your visit threshold is $40 so in other words, if you make 40 only,
you can only pay for your office, not for yourself, not for your home. So certainly you have to have a much higher
reimbursement. So in this case, if you’re getting a $40 reimbursement from [ASH 00:00:04:00],
you’re actually having zero profit unless it brings in a new patient. So really that’s
the issues we have to deal with. So here’s something of course that we use last time
that we talked about the company of American Specialty Health and their management of Blue
Shield of California. There’s been a lot of people wonder, “Well, what’s going on?” Well,
you’ll notice right here in the second line, it indicates towards the end in a significant
number. What this means is American Specialty Health is certainly contracting with some
Blue Shield plans. But not all. I can state not all, because if it were a majority of
plans, I’m pretty sure they would indicate majority, but they chose the word significant.
In addition, you’ll notice the date here is September 6th, it says that’s the date you
have to sign up. Now, what I found interesting, this doesn’t
begin till January. Then why such the push for this date here? Well, partly it’s because
if they didn’t get enough numbers that it’s going to be an issue. But let’s talk about
if you join. What does this mean? Well, if you join, the exams are between 30 and 40
or for a new patient, 20 and 30 for establish, for the first set of acupuncture, $41, second
set seven… Which I will say makes no sense, but whatever. Then the therapies are all $10
no matter the type. They do allow home visits, but I think the big issue, and I put it in
red here, it’s a $48 per max visit and it’s inclusive. So I don’t care what services you
provide. The most you’re going to get is $48 per day. So chances are you’re going to max
out each time unless you just do one set or don’t do any other treatment along with that
patient. So to me that’s a pretty difficult management
prospect for that type of money. That being said, that’s better than what they’re paying
on some plans now but not much better because it’s only 42. There also will be a five visit
threshold for in and out of [inaudible 00:05:41] network fees are same for an order network.
Now this is where I want to speak to everyone. If a plan will pay you the same amount of
money out of network as in network, why would I join NBB Holden, if they have control over
what I do, how many visits? This way you have a little bit more control over what you’re
doing. So what’s really occurred here is by September 6th and I’m awaiting to hear and
that’s why I wanted to do this show today. I’m waiting to hear whether or not they got
a high enough percentage of acupuncture and chiropractic providers who will participate
because otherwise ASH would not get this contract. Now I want to be careful. I’m not saying it
all ASHer’s a bad company. They’re certainly there to help with management and so forth.
However, the issue becomes most people [inaudible 00:06:25] acupuncturists are getting paid
the same amount of money as anyone has been paid for the last 10 years. So what I’m getting
to here is if you’ve been paid the same amount of [inaudible 00:06:48] I don’t anyone that
did, I’m not so sure this was a viable benefit considering the patients will still have the
same. Consider the patients will have the same type of benefit whether they’re in or
out of network. So something I want you to keep in mind is in joining these plans, you
certainly want to understand that. What am I going to get out of it as a provider and
will this be viable for my office? Do I really want to join? And the interesting part will be will they
actually get this contract. Now, the next factor that’s gone on, and this is also what
I want to update [inaudible 00:07:29]. So you notice it Says Horizon Blue Cross Blue
Shield will be contracting as of January 1st. Now this is going to be a little bit different.
You will definitely have to join because it’s going to be covering all aspects of acupuncture
or chiropractic, occupational therapy and physical therapy, but the big issue is it’s
going to be the majority of plans. You’ll notice this guideline includes all of the
fully insured plans, federal employee Medicare advantage, self-funded and apply to fully
insured members enrolled. In other words, it’s only not going to include the plans you
see here, New Jersey health plans, TotalCare and Medicare supplemental. The difference
here is when you join in order to stay in network with Blue Cross Blue Shield of New
Jersey or Horizon, you must join ASH. Now, this is a bit different in this sense.
The good news is on these plans though, you’re going to join ASH. It is not going to change
the pricing. All they’re going to affect is the amount of visits or the medical necessity.
So it is going to be a mandatory thing that you will have to do to sign up if you want
to remain in network. Now if you get out of network, will they still have benefits. Yes,
but these benefits will be far less. And remember if you are out of network with this plan,
they are going to, of course, not send the check to you. The check is going to go to
the patient. So something to keep in mind. I think here what’s important to really focus
in on is that what they’re looking to do in New Jersey is really just control the number
of visits. As I’m sure you’re aware, many patients with
these plans get anywhere from 25 to 40 maybe 50 visits per year and often a patient feels
that if they get those visits, they’re allowed to use them at their leisure. And unfortunately
that’s not really what it is intended for. It’s intended for them to use when it’s medically
necessary. So certainly what ASH is coming in to do is
really look at the medical necessity. So what they’re going to be doing is looking at clinical
performance. With this new system, everyone probably will come in with probably about
five to 12 visits allowed and then from there you’ll have to request more. Now this is where
ASH will make a difference. What they’re looking to do is just really manage to make sure care
is medically necessary. And what I want you to focus on, and this goes with anyone regardless
of the plan, they’re going to look for significant durable pain, intensity decrease. What this means is focus in on the patient’s
pain level, but not a pain level related to when it’s at its worst. It’s a 10. Tell me
how the pain level is affecting their function. So if a patient has a pain level of an eight
this week, you want to know what does it effect you doing? Can you not sleep through the night?
Can you not tie your shoes? Can you drive your car? But any type of activity and then
when it goes down to a six, how those improve? The other factor that they focus on is functional
improvement and what they noted is by clinically meaningful improvement on validated disease,
specific outcome instruments returned to work or documented improvement in activities of
daily living, and with this would be the emphasis… When you’re treating someone in their pain
is reduced, they are going to feel better with pain, but their function is better. Always highlight something specific about
the patient’s function or ability to move, ability to do a task that [inaudible 00:10:51]
which means they’re looking at guidelines that indicate acupuncture works pretty well.
Most patients within two weeks of care certainly should have a pretty significant change in
function and pain. If there’s none, then obviously care is not going to work and it doesn’t mean
that everyone gets well in two weeks, but there’s a high expectation generally that
many patients with their six to eight visits for most manageable things generally will
focus in or will probably reduce their pain greatly within that time. Meaning it’s going
to be harder to get much more from it unless it’s a much more severe problem. So one of
the things they also look at is complicated and comorbidity factors, so complicated and
co-morbidity factors. These are things that you aren’t necessarily treating directly but
affect recovery. Think of patients with arthritis, with chronic
pain patients with underlying diabetic issues, patients who are severely overweight, patients
who are just unhealthy and any other way, anything that you can highlight as to that
might increase care. That’s where the issue’s going to be. You’re going to have patients
that are going to need more than six or eight visits. The good news is many only need that,
but those that need more, we should be able to document the why. The other factor that’s gone on and you’ll
see here is some listing for veterans and this is probably caring for veterans and I’m
sure many of you are aware of the good veterans choice program or what I should call the Community
Care Network For Veterans. However, there’s been some updates. The Veterans Community
Care [inaudible 00:12:22] now is being managed not only by the company Triwest. So for those that remember in the past, Triwest
was managing the West coast and a company Health Net was doing the East coast for the
most part. They made such a mess of it, I should say Health Net did that Triwest was
given the full contract, but frankly I think Triwest was having a hard time managing all
of those. So now they’ve awarded an additional contract to the company OptumHealth who is
essentially United Health Care to manage the new networks or a different set of networks
out of state. So here’s what I make sure Triwest now handles what’s called region four and
you’ll see all the States represented here basically from Texas all the way over is through
Triwest. So if you’re in these States, you will maintain working with Triwest directly
for all the community care network. However, every place else is going to be through
OptumHealth. So regions one, two and three which are all the States, basically East coast,
Texas and on the East. The difference is this isn’t all occurring overnight. It appears
it’s being rolled out in sections. So you want to verify when your area’s going to change
over because it’s going to be managed there. Because obviously for the VA you must have
direct authorization and we have to make sure who were going through. So I want to make
everyone aware on a basic term the West coast will be Triwest, on the East coast will be
handled by OptumHealth. You will have to enroll directly with OptumHealth but they’re not
very difficult. You can go right to their site. It’s my and click on
provider enrollment. There is no charge to do so. Also one last note for today, just an update
since we’re talking about United Health Care. This began September 1st though in some States
I think it began a little earlier and it’s to remind you all physical medicine codes.
That means everything from a hot pack to an unlisted therapy require what’s called the
always therapy modifier, which is GP or it will be denied. So you want to think of if
you’re going to build heat 97026, you’re going to put a GP modifier on it as well. This modifier
is required for all plans that affiliate with United Health Care, so this would include
OptumHealth as well. So again, highlight physical medicine codes require a GP. Acupuncture does
not, but physical medicine, if by chance it’s a code that needs an additional modifier like
a 59 you will need to have both modifiers, but the order of the modifiers, it does not
matter. You may use 59 GP or GP 59. I do want to highlight
though, please make sure to include the GP or they will deny you. In fact, if you call
them because they will indicate on the denial you’re missing a modifier. If you ask them
what modifier was missing, they literally will not tell you. Now this is Sam. Again,
I definitely want you to always be on top. Our news section contains always information
on what’s changing. So if you go to our Facebook page or to Instagram, we put a news item there. Please go to our site, which is
Take a look there in the news section. We are always there to give you information,
look on the news section, but also just look on the highlights. We have upcoming programs
to really help to make sure your practice is succeeding. We’re your number one advocate,
the American Acupuncture Council For Malpractice Insurance And Seminars wants to be sure you’re
doing well. I thank you for the time and next weeks host will be Lorne Brown. Until then,
take care everyone. Please subscribe to our YouTube Channel (
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