The Acupuncturist s Guide to Insurance Credentialing. Jamie Smith & Valondra Nimrod
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1 The Acupuncturist s Guide to Insurance Credentialing Jamie Smith & Valondra Nimrod
2 QIP Needs analysis Topic- Credential process for new acupuncturist Target audience- Recently Licensed Acupuncturist Needs analysis- Many new practitioners work with cash only patients because the credentially process is too confusing and daunting. Intervention- Step by step class for getting credentialed in the State of Texas Outcome measures - Survey at the end of the class on the understanding of getting credentialed. Possible before and after of who plans to take insurance. Results- Will be measured by survey Conclusions- We will see if helping educate new graduates/ acupuncturist on how to get credentialed could help them become more successful in their acupuncture practices.
3 Pre-Survey 1. Do you currently/ or want to start accepting insurance for acupuncture? Currently Accept Yes want to No do not want to 2. How interested are you in taking insurance? Not interested A little interested Neutral Somewhat interested Very interested 3. How confident are you in your understanding of what the credentialing process looks like? Not confident A little confident Neutral Somewhat confident Very confident 4. How how likely are you to take the steps to getting credentialed? Not likely Somewhat likely Likely Very likely
4 Step 1- Decide whether or not taking insurance will fit into your business model.
5 Step 2- Evaluate the Pros and Cons For you and your Business!
6 Pros of Accepting Insurance 1. Free advertising for your business 2. Patients may come more frequently (typically treatments covered per year) 3. More affordable for patients 4. Patient who might not normally try acupuncture might because their insurance covers it. 1. Higher volume of patients
7 Cons of Accepting Insurance 1. More time spent on dealing with insurance companies 2. Billing process may take more of your time, than cash patients 3. Delayed payment 4. Compensation may vary, possibly less per service. 5. Some services not covered with insurance (cupping, tuina, gua sha) 1. Insurance does not cover all chief complaints.
8 Step 3- What you need to take the next step 1. State License Number 2. National Provider Number (NPI) 3. Tax Id Number (EIN) 4. Social Security Number (SSN) 5. Fax line number
9 State License Number Must be licensed before beginning this process! Where can you find this number if you do not know your number?
10 National Provider Number (NPI) Who is eligible for an NPI? In general, a health care provider, a group of health care providers, or a healthcare facility that furnishes medical services in the normal course of their business is eligible for an NPI number. Individual health care providers eligible for an NPI include physicians, dentists, psychologists, pharmacists, nurses, chiropractors and many other health care practitioners and professionals. Getting an NPI is free!! Where can I apply?
11 Tax ID Number (EIN) Where does this number come from? The IRS Where can I get this number?
12 Fax Number Why do you need this? A secure line for sensitive information is needed to be compliant with HIPAA standards Solutions? compliant Fax day free trial! $10 dollars a month, for HIPAA Local to Austin, with a 14
13 Step 4 - Deciding... Decide which insurance companies you want to be credentialed with. Ask other providers in your area who they have had better experiences with. Ask current patients what insurance they currently have, even if their insurance does not cover acupuncture, it may in the future. Pick a good amount of companies to start with, as you might not get them all. Ten to fifteen insurance companies is great start. Find out which insurance companies cover which chief complaints
14 Medical Billing Options Finding a company that can handle the billing for you will save you time! Allowing you to make more money! Local Options: Storm Medical Billing Texas Professional Medical Billers Puredi -Manages all of you billing & re-credentialing needs.
15 Insurance Companies Unitedhealth Group Kaiser Foundation Group Humana Group Aetna Group HCSC Group Cigna Health Group Wellpoint Inc. Group Coventry Corp. Group HIP Insurance Group Independence Blue Cross Group Care First INC. Group There are more, but be wary some might not cover acupuncture.
16 Coverage varies company from company... Aetna considers acupuncture Medically necessary for: Chronic (minimum 12 weeks duration) neck pain; or Chronic (minimum 12 weeks duration) headache; or Low back pain; or Nausea of pregnancy; or Pain from osteoarthritis of the knee or hip (adjunctive therapy); or Post-operative and chemotherapy-induced nausea and vomiting; or Post-operative dental pain; or Temporomandibular disorders (TMD). And Experimental for all other conditions
17 Step 5- The Applications In Texas, there is the Texas Standardized Credentialing Application. It is 20 pages long. Fill out the application in its entirety. Anything left blank will be red flagged and could put your application on hold. Some insurance companies have an online version of this. It will take some time for you to fill it out, so fill out one application and then reuse the information.
18 Step 6- The Follow Up It can take up to 6 months to get credentialed with some insurance companies After you have submitted your application and any documents they need, wait 2 weeks and call to check to see if there are any documents pending with your file Once you get the Yes we have everything that we need, starts the second waiting game. Wait about 4 weeks before calling again to check the status of your application Your file should move from the credentialing and approval phase, to the contracting phase.
19 Step 7- The Contract Look over the terms very carefully Have your legal representation look over the documents as well Review the terms and length of your contract. Check the contracted rate for in-network vs out-of-network Length of time before you get paid And, instructions for disputing or filing an appeal for a claim If you don't agree with any of the terms, DO NOT SIGN You can always try and negotiate different terms or a higher contracted rate. BUT there is no guarantee that they will change anything.
20 Questions
21 The Recap 1. Decide whether or not taking insurance will fit into your business model. 2. Evaluate Pros and Cons 3. Items you need for the next step 4. Deciding which companies to apply for 5. The application 6. The waiting time 7. The follow up
22 The Post-Survey 1. Do you currently/ or want to start accepting insurance for acupuncture? Currently Accept Yes want to No do not want to 2. How interested are you in taking insurance? Not interested A little interested Neutral Somewhat interested Very interested 3. How confident are you in your understanding of what the credentialing process looks like? Not confident A little confident Neutral Somewhat confident Very confident 4. How how likely are you to take the steps to getting credentialed? Not likely Somewhat likely Likely Very likely
23 The End
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