+What is a Billable Condition?

Many insurance plans will only cover acupuncture for certain conditions and each plan is different. If your plan restricts coverage to certain conditions, we can only bill your insurance if you have one of those conditions and it is significant enough to affect your daily life. We have to be able to show that treatment for the condition is "medically necessary".

When you are being treated for a condition that your insurance is covering, you will need to talk about that condition and discuss any developments at each of your acupuncture appointments so that your practitioner can document appropriately as they are treating you. Be sure to read the What Questions Should I Ask My Insurance Company? section below for more guidance.

+How many visits are covered per year?

Your insurance plan may specify a numerical visit limit per calendar year, or may specify that you have “unlimited visits based on medical necessity.”

If you have a numerical visit limit it is ultimately your responsibility to keep track of your number of visits.

If your plan states that it covers “unlimited visits based on medical necessity”, that does not mean that they will cover you coming in as much as you want to, all year long. Insurance plans with unlimited coverage still require that treatment is due to "medical necessity" and want to see that your condition is improving over a course of treatment.

+What is "Medical Necessity"?

Even if your plan does not have diagnostic restrictions, and even if your plan offers "unlimited visits", SBFA can not bill your insurance company unless we can demonstrate that your treatments are “medically necessary”. Medical necessity is demonstrated when there is:

A condition significantly impacts your life and activities of daily living.

A significant improvement in symptoms over the course of treatment, and

An end to the treatment window

For this reason, we need to manage the amount and frequency of your appointments. So while you may come weekly at first, as your condition starts to improve, we will need to start spacing out appointments over longer periods of time and eventually end your treatment window to meet the above conditions. Coming every few weeks for a long period of time is viewed as maintenance treatment and is not billable to your insurance.

If the condition we are billing for improves but we are still treating you for other reasons, you may need to pay out of pocket for a period of time. You can always tell us if another billable condition arises and we can start a new treatment plan for that condition.

+ What is a deductible?

A deductible is the amount of money that your insurance policy says you must pay towards medical expenses each year** before your insurance begins to pay. A deductible is different from a premium, which is the monthly amount that you pay in order to get your insurance coverage. The money that you pay towards your premium does not count towards your deductible.

Some plans do not require you to meet a deductible for your acupuncture visits, and they just assign a copay to the appointments. If you have a copay for acupuncture, you usually don't have to meet your deductible first. If you have a coinsurance, usually listed as a percentage, then you do typically have to meet the deductible before your carrier will start to pay for part of the treatments.

What Will I Pay At Each Appointment While I'm Meeting My Deductible?

What you will pay depends on your plan's reimbursement rates for the codes we bill. If you need to meet a deductible, we can usually tell you what you will owe for each appointment based on your insurance company.

After you meet your deductible, then you will pay the percentage co-insurance for each visit while your insurance covers the remainder of each visit. That % is calculated based on what you paid for each visit towards your deductible. So for instance, if you paid $100 per appointment while you were meeting your deductible, and you have a 30% coinsurance, then you will owe $30 for each appointment after you have met your deductible.

I Have A Visit Limit - Will That Start Counting After I Meet My Deductible?

No, unfortunately. The visit limit starts counting from your first appointment, whether the payment went toward your deductible or not. That means some people with higher deductibles may meet their visit limit while still paying toward their deductible. We wish it weren't like that, but if you end up having any big healthcare costs this year, being closer to meeting your deductible will be a benefit.

Understanding Your Benefits

When you become established as a new patient our admin team will inform you about what we expect the full cost of an appointment will be. We always try our best to estimate your out of pocket expenses, but ultimately, it is your responsibility as a patient to contact your insurance policy carrier and inform yourself about the specifics of your coverage. The best way to verify your coverage is to call the Member Services phone number on the back of your insurance member ID card.

(**Most deductibles begin on January 1st of a new year unless special circumstances arise. For example, if you acquire a new insurance plan through a job beginning on March 1st, your deductible begins on that date but will reset on January 1st of the following year. Some insurance policies reset with the beginning of the fiscal year on July 1st– typically this is seen with public school or public office insurance plans.)

+ What is a copay vs a coinsurance?

A copayment (copay) is a specified, consistent amount that you will pay at the time of service of an appointment. For example, if you have a $30.00 copay for acupuncture services then you can expect to pay exactly $30.00 at each visit. In some cases, the first appointment may have an additional copay because of the extra work we do to get your health history, evaluate your case, and come up with a treatment plan.

A coinsurance is a percentage-based split of payment for services between a patient and their insurance coverage. This percentage split is designated by your insurance policy. For example, if your insurance specifies that you have a 10% co-insurance, then you would be responsible for paying 10% of the provider’s reimbursement rate while your insurance pays 90%.

How do you figure out your percentage payment responsibility amount? At our office it is our policy to let patients know what their financial responsibility is in the case of a co-insurance benefit. For example, if you have Anthem insurance with a 10% coinsurance, we will let you know what the full charge for that visit is based on Anthem rates and what 10% of that amount will be, and collect that from you at the time of service. Then we will bill your insurance and expect the reimbursement to be completed by them as expected.

+Why am I paying a different rate than the self-pay rate?

Our practice is contracted in-network with insurance companies so that you can use your insurance benefits with us, and with that contract comes a legal obligation for us to not only bill your insurance but to charge you at a rate that the insurance carrier has determined. Different insurance companies and plans reimburse at different amounts. The rate that you pay is determined by your insurance company based on the standard codes that we bill.

+Why is there an additional charge for the first appointment?

The first appointment is longer so that your practitioner has time to review your full health history and get a clear understanding of your current symptoms. We also follow up after the first appointment with a recommendations email.

Some insurance companies charge an extra copay for this initial intake, while others do not cover it at all and leave you to pay that amount. We always do our best to let you know ahead of time what the charges will be, but sometimes there may be an additional copay that we weren't expecting for the first appointment.

+ I had three doctor’s appointments in January before I had my acupuncture appointment, won’t I have met my deductible already?

Our practice is much smaller than the average doctor’s office and we typically bill insurance for patient claims within 14 days of each date of service– and sometimes much more quickly than that. Because of this speed of billing, our claims will often be filed long before other, larger, offices file their claims. Therefore, your deductible can be met with us even though the visits occur after the doctor’s office visits. We may request that you pay our office towards meeting your deductible and can always refund money to you if it turns out that your deductible was met elsewhere.

+Why is the insurance company saying I owe a different amount than what six branches was told?

Although we do our best to verify your correct benefits information fully before you become a patient with us, there is always a disclaimer from insurance companies when they give us that information that says, “declaration of benefits is not a guarantee of coverage.” In other words, a company can tell us one thing but it may not actually be the same as what they declare when the claim has been processed. We do see this happen on occasion, unfortunately. This discrepancy can arise from human error on the part of the insurance company representative when they are interpreting benefits information, or from a system-wide failure to update at the insurance carrier’s offices– or other unknown reasons.

In the case that such a discrepancy arises and we see that your insurance company is holding you responsible for a higher amount than you were quoted in your benefits check, we will reach out to you as soon as possible to keep you informed. We generally receive a processed claim back from insurance 4-6 weeks after we submit it.

+What questions should I ask my Insurance company?

We do our best to help you navigate insurance coverage, but ultimately it is your responsibility to understand your benefits.

We recommend calling the Member Benefits number on your card to ask the following questions. Always ask the representative for a reference number for the call.

Do I have coverage for acupuncture? (CPT codes 97810, 97811)

Do I need a referral from an MD or Primary Care Provider in order to be covered?

What is my deductible? Have I met it? Does my deductible apply to acupuncture coverage

What is my copay or co-insurance?

How many visits am I allowed?

Is the ICD-10 code for my condition covered under my plan?

ICD-10 codes are used for diagnosis. For instance, low back pain is M54.50. You can look up the ICD-10 code for your condition here and below we have provided a list of common diagnosis codes for you to check with your insurance plan:

Neck pain M54.2
Chronic tension-type headache G44.229
Chronic Migraine G43.009
Low back pain M54.50
Pain in right shoulder M25.511
Pain in right hand M79.641
Pain in left hip M25.552
Pain in right knee M25.561
Pain in right ankle and foot M25.571
Epigastric pain R10.13
Anxiety, unspecified F41.9
Painful periods N94.4
Female infertility, unspecified N97.9

Knowing this information will help you understand the insurance billing process a little better.You are responsible for understanding your insurance benefits and will be responsible for paying for any services that are not covered by your insurance.

A Note For Aetna Subscribers:

Aetna has a very limited list of conditions they will cover. Even if they say you have acupuncture coverage, in most cases, they will only cover for the conditions listed in this bulletin: https://www.aetna.com/cpb/medical/data/100_199/0135.html