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Insurance: One Practitioner’s Experience

by Rev. Dr. Sandra Lee Manasco, D.D., Ph.D., DOM

Regardless of how any one person feels about health insurances, everyone pretty much agrees dealing with them is a painful experience.

I debated with myself for a long time as to whether it would be worth it money-wise to take insurance as well as cash in payment for my fee. I learned that most patients can’t afford a cash payment on a regular basis, no matter how small the fee. The sort of patients I’ve treated required several sessions in order to see results. After one or two treatments my patients would begin to cancel due to the fact they couldn’t afford my more-than-reasonable fee. I would hear the same question over and over: “Don’t you carry health insurance?” It didn’t take too many of these repeat performances for me to get the idea that in order to survive I’d need to give my patients more choices.

I began a campaign to find out what successful practitioners were doing in terms of fee payment. The first thing I learned was that they all take health insurance payments. The second thing was that they all have flexible payment schedules. For example, discounts for seniors, state employees, cheaper fees or a free treatment for blocks of treatments, and sliding-scale fees. I was already doing most of these except for the insurance payments. When I was able to coax out of them what percentage of their payment came from insurance, most practitioners stated that 55% or more was the average rate. That percentage seemed high to me.

It encouraged me to get on the insurance bandwagon. Little did I know that the bandwagon would take me on one wild ride that isn’t over yet.

The first problem I encountered was: How do I become a provider? I was so innocent about the process I didn’t even know that provider was what I wanted to become. I quickly learned that insurance companies have a language all their own. Provider, patient, member— sounds simple, but not if your mind is working on medicine rather than insurance.

I had taken a course on insurance know-how, but it wasn’t that helpful in the actual process. Just Googling health insurance on the internet wasn’t a lot of help either. By trial and error I’ve worked out a few roads of safe passage. A map beforehand would have been preferred.

Here’s a map for anyone who might want it.

First decide what insurance companies you want to join. Many practitioners wait until their patients present them with their insurance cards to begin the process of becoming a provider for that company. DON’T WAIT! The average wait from beginning of the credentialing process to a signed contract is six months. That’s considered fast. The reason it takes so long is that insurance companies have a quota system based on member need, or so they tell us. I’m sure it has nothing to do with the idea that insurance companies don’t want to pay out more money than they absolutely must. Some HMOs haven’t changed their basic quota numbers in years even though the population of any given area has risen dramatically over time.

The Department of Worker’s Compensation has a list of insurances that take worker’s compensation, but that may not be of much help. In this article I will list the major companies here in New Mexico and walk you through the basic process of application for some of them.

After you have assembled a basic list of five or more insurances (starting small is best), then form your insurance application packet. This is a packet of information required by all insurance companies. Some companies require you apply online with the choice of a paper application. I suggest starting with a paper application if possible. It will be a bit mind-blowing, but once you get through one, any other application will seem relatively easy.

You will need: a copy of your license, IRS Form W- 9, curriculum vitae, current resume for the past 15 years including time in school, and copies of any other medical type licenses/ certifications you may hold, even if they are not applicable to the insurance you’re applying to. Also, you will need at least three references from the same field of medicine. They cannot be people you work for or are in association with in the same clinic. Some companies don’t require this last stipulation, but most do. You will also need your malpractice insurance face sheet. That’s a single sheet of paper sent to you by your insurance company with the date of insurance, by whom, and amount and type of insurance. On my sheet under the company logo is the title, Declarations to Claims-made Professional Liability Policy. It is signed by a company representative. Some HMOs require you carry at least a million dollars in malpractice insurance. You’ll want to check this out before deciding how much malpractice insurance to get. Being underinsured could dump the whole process.

Have your national provider identification number ready. If you don’t have one, get one before you start the insurance application process. You can apply for it on https://nppes.com.hhs.gov, or call 1-800-465-3203 or NPIenumerator.com. This is a national provider ID that most companies are using now. You’ll need it when you file a claim. Also, you may need it for electronic filing of claims. Keep the original notice of your NPI, as some companies require a copy of this also.

Some tips here. Don’t make your resume more than four pages. Each category should list name, address, and phone number of where you worked or went to school. Also include the exact dates, what your work title was, even if you have to make it up, and one sentence describing what you did. Here’s an example of one of my work histories:

International Institute of Chinese Medicine Nov. 2002- July 2003

4600 Montgomery, Albuquerque, NM 505- 883-559

Teacher – Medical Hypnosis

Created and implemented a medical hypnosis course for school interns

Start with your last employment first and work down fifteen years. Don’t pay someone for a professional resume; you’re not applying for a job. They just want an overview. If you have a long list of credentials or certificates or even seminars you’ve given, list these here rather than in your curriculum vitae. I’ll give an example of my vitae at the end of this article. Always think less-is-more in reference to your resume and curriculum vitae.

You can get the tax form W-9 online at IRS.gov, or go to or call your local IRS office and request this form.

I use my social security number as my tax ID, as I list myself as a sole proprietor rather than a corporation or other tax listing. If you have lots of assets (money, houses, cars), or intend on getting them, you may want to set up as a corporation or other tax category, in which case the IRS will give you the tax ID number. (For this you will need to consult a lawyer.)

One thing you don’t need to have is a DEA certificate. That’s a federal certificate to prescribe addictive drugs. You may need proof of extended prescription authority, but it’s doubtful. You don’t need a CAS certificate, as this is a state certificate to prescribe addictive drugs. You don’t need a worker’s compensation certificate of coverage unless you employ three or more people including yourself in your clinic. That does not mean people that rent space in your clinic. If you have a split-fee arrangement with two or more DOMs, you will probably need this certificate and coverage. Call the department of worker’s compensation to make sure.

Once you have this insurance application packet assembled, the application process should go rather quickly and smoothly. Use a black ballpoint pen in filling out the application, not a pencil. This simple mistake will reject your application immediately. Make a blank copy beforehand in case you mess up. Most companies won’t allow you to use whiteout.

The main problem is finding out where and how to get the actual application.

Some insurance companies you can reach on the internet, for example, AETNA. Go to their website and click on provider or professional healthcare services. They should have a link that states “Join network.” Click on that for either an online application or to ask for a paper application. The insurance company will send you the application that will then go to the credentialing service. Some you will have to call to get a credentialing ID number first, such as CAQH. You can either apply online or print out a paper application. Make sure you have all the needed information before you begin an online application. Let me walk you through one company’s process:

UNITED HEALTHCARE INSURANCE > call 1-877-842-3210 (automated menu) > pick > Healthcare professional services > then pick > medical > then pick > join network or listen to the overview (which doesn’t help much); system sends you to a live person HURRAH! Do you want to join the network? Yes. Questions: Name, tax ID, specialty (Acupuncture), primary place of business, billing address (always use your home address) fax number. The representative will then give you a CAQH ID number. Write it down and don’t lose it. They will then fax you or send you a packet explaining their procedure. You may have to call the help desk for the paper application ( 1-888-599-1771) if you want one. The information packet will tell you how to go online to fill the application online, or it will have the paper application.

CAQH is a nonprofit credentialing service used by a great number of insurance companies. When you get to the end of that application be sure to state > release to all. You want to do this because if you apply for another company that uses CAQH all you have to do on their application is use your ID number. It saves time for a lot of companies and for you. It takes about 60 days for the credentialing to process. You can call 1-877-842-3210 >pick healthcare professional services > pick status. They will then let you know where you’re at in the process. You will also get a written notice in the mail. That doesn’t mean you are ready to take insurance patients. You now have to wait on the insurance company to approve you as a provider. A hint here: if they disapprove you you’ll get the notice quickly after the 60 days. Actual approval takes longer, 90 – 120 days. They will notify you by mail of your approval. But you’re still not ready to treat insurance patients yet. You have to wait until the contract is signed. From that signature date is when you can file claims. Can you treat then file at a later date? Yes, up to a year, but you cannot file a claim for a treatment before the contract date, nor in advance of a treatment.

By the way, CAQH’s paper application is 18 pages long with seventeen pages of supplemental paperwork. The whole application is 43 pages. Unless you’re a computer wiz I suggest doing this application by paper. It will give you time to think and not tie up your computer forever. Once you get the application, fill it out and fax it back within 30 days. CAQH has the option to deny your application just because it wasn’t sent in the correct time frame. Always triple-check your apps. Let it rest a day so that you’re clearheaded, then go back and look it over carefully. One little mistake can cost you months of waiting. If you’re not sure of the question or the answer, call their help desk or provider service number. Most will have this number with the application. Always keep copies of everything you send. Your might want to keep a phone log as well.

Before you begin, you might consider what could improve your chances of getting approved by the insurance company. Speaking Spanish is a real plus. Also, sign language ability is a good skill to have. Do you have a nurse’s license, therapist credentialing or massage license? Even being an ordained minister may help. There are many companies that pay for grief counseling. Even though our practice act states that we can do counseling, too many people are totally unaware of it. List any and all of your credentials/certificates and licenses on the application. This can only help you get approved. After finishing one application, the process becomes much easier.

Once the credentialing process is done and the contracts have been signed, now comes the fun part of actually getting paid. Some companies such as BCBSNM encourage you to file online. They use the Availity filing service. Just go to www.availity.com to register and learn how to do electronic filing. It’s not as hard as it sounds. It saves time and money for both you and the insurance company. I suggest starting with a paper claim first. You will need to purchase the current forms. Go online and Google medical forms to see the hundreds of companies that supply these forms. You will need a current ICD-9 code book (about $45). It might be easier just to ask someone you know who has the current codes for a copy. [ICD codes are available for free on the Web at icd9.chrisendres.com.— Ed.] In the future, in a galaxy far, far away we’ll be using the ABC code system. There is an enrollment period that has been extended repeatedly. To enroll, Google ABC medical codes online. There is a whole website just for these codes, enrollment and info. They were designed to make insurance claims easier, especially those people that work in the natural medicine field. I wouldn’t wait to need them before you enroll. Our present insurance codes have quite a few of the necessary codes that we use.

Remember not everything is paid by every insurance company. Go over the contract and enclosed provider’s manual of every insurance company to learn what and how they pay. Do have your patients pay for their deductible and copays. They know they have to do this. Don’t lower your fees because the insurance companies won’t pay the full price. The companies will upgrade their fee schedule eventually. Constantly lowering your fees keeps the fee payment down. The insurance company expects providers to list each thing they do for the patient separately, including medical massage. Some companies won’t pay for medical massage unless approved by them first. Go ahead and treat your patient as you wish, and get the approval before you file. Some companies, like Lovelace, won’t pay for anything but acupuncture. Lovelace does have Medicare Senior Care for acupuncture now, so that it still might be an insurance you want to carry. BCBS is considering acupuncture for their Salud patients as well.

Do not list more than four items on your claim, as this will probably cause a denial. Do charge every four visits of a continuing treatment course for evaluation (although some insurers won’t pay for this). Let’s say you charge $70 for a standard visit that includes massage and cupping. On a first visit your total charges may range up to $250.00; of that amount you might get $70 - $80.00 total if the deductible has been paid. If the patient hasn’t paid the deductible but has paid you the difference, list that on your claim. How do you know if they have or haven’t paid? Call while they are on the table. Ask what the copay for each treatment is and if this patient has met the deductible for the year. You will also want to know how many times a week, month, and year that they can get acupuncture treatments paid for. Every company is different and plans are different within each company. Some companies, such as Lovelace, have a set fee for all acupuncture treatments. They don’t pay more for the first-time visit. You can still list it on your claim; they just won’t pay you more for it. Some pay for cupping, some don’t. Some, like BCBS, will pay for supplies you use during treatment (needles, tape, herbs). I suggest you go easy on this item.

Don’t sign up with companies that want you to agree to a percentage off your fee for a listing in their network. They don’t pay you a dime, nor will they get you patients as they say they will. Some states differ in what they pay or won’t pay. BCBS of North Carolina only offers percentage-off compliance, while BCBS of New Mexico offers a fair payment for services, and just recently upgraded their fee schedule.

Start folders for every insurance company you use. In each, file the date of treatment, patient’s name, birth date, patient member number, date submitted and date payment was received. Insurance companies are supposed to pay within one month unless the claim is denied or red-flagged. That’s the law. Don’t stop just because of denial. Find out what the problem is and fix it. The EOB (explanation of benefits) will list why the claim was denied. The companies also have arbitrators that are there just for the purpose of helping to solve the problem. If a company has gone over the 30-day pay/denial period, call them. They won’t call you.

Here’s an example of a curriculum vitae:

Name/Address Date

To Whom It May Concern:

This letter is a short resume of my qualifications in the field of Acupuncture and Oriental Medicine. I graduated so & so date with a masters in Oriental Medicine from so & so school. (Don’t give your grade point average unless it was 4.0.) My classes included Anatomy, Western Pathology, Acupuncture etc, etc. (Don’t list more than 12 classes and make sure they apply to what you do; I’d leave off Tai Chi for example.) List all medical schools or like schools (massage etc.) that you attended. Do not give the classes for anything other than the Oriental medicine school you attended. List your clinical internship. If it was in China as well as your school, list them both. List your license number as well as when it was first issued. Also the NCCAOM certification number/s and any other license numbers or certification numbers you have. Sign sincerely and your name. Typically a curriculum vitae is no longer than one page. Remember you are going to send them a longer work resume. This is just a short document going over what classes you have taken, internships and licenses in the field in which you will be filing claims.

My experience in learning how to be an insurance provider is an ongoing one. With each new application, claim, and patient, I have become more confident in dealing within the insurance arena. Is it worth it? For me the answer is yes. I suggest trying the insurance claim game before deciding one way or the other.

If you have any questions please feel free to e-mail me at sandraleemanasco@aol.com