ACUPUNCTURE AND INSURANCE IN NEW MEXICO #1 [Summer 2004]

ACUPUNCTURE AND INSURANCE IN NEW MEXICO, Installment One

As a recently licensed DOM, among the many things to learn, the world of insurance is one of the most confusing. In an effort to gain information, I volunteered to be on the Insurance Committee for OMANM. I became the Insurance Committee and found the Board of OMANM to be willing and receptive to share their knowledge. What follows is one of those most rare and privileged conversations allowing a glimpse into acupuncture as it is practiced in New Mexico and the role insurance plays in those practices.

First, please tell us what your board or committee position is with OMANM. How long have you been in practice, where at present, and what distinguishes your practice? Is it particular age group, do you treat particular ailments more than others?

Do you accept insurance? If not, what do you do to accommodate those with insurance coverage? Are you affiliated with a group that negates the need for insurance or collects on your behalf? What percentage of your practice is based on insurance? Do you complete the insurance forms or does someone else? What have been the pitfalls as well as the successes with collecting insurance? If you had it to do all over, what would you do differently? What do you think needs to happen between insurance and acupuncture?

REBECCAH RODRIGUEZ: I'm new to the OMANM & was elected Secretary at the last annual meeting. I've been in practice for 2 1/2 years. I've spent the last year in private practice in the NE, near the Coronado Mall, Prospect Professional Medical Plaza. My practice is pretty general at this point (i.e.. pain, stress, sports injuries, internal medicine) but I'm interested in women's health and HIV care. I treat mainly adults (more women than men). I also run a Pain Clinic in the Southeast Heights Family Practice Center, which was originally a research project treating Vietnamese refugees for post traumatic stress, pioneered by Dr. Nityamo Lian. Here, I mainly treat pain with members of the Vietnamese and Spanish-speaking immigrant population in the Southeast Heights.

LEE LaBRIER-MORTON: I am an OMANM member for 2 years and current member of website/PR committee.

I have been in practice for 5 years. My office is located at 7400 Montgomery NE. I joined an existing practice with a chiropractor, nutritionist and massage therapist.

The majority of my patients are women dealing with musculo-skeletal pain. Since completing the EX/RX certification I am seeing more people for consultations regarding supplementation, nutrition and lifestyle changes to deal with more intractable disharmonies.

QUINN AKIRA-TAKEI: I am a board member of the OMANM, no specific office. I have been on the board for about a year and a half. I have been in practice of over 3 years. I really don't specialize in any one thing. However it appears I see many patients for the following ailments: gynecological, geriatrics, pain, and respiratory disorders.

REBECCAH RODRIGUEZ: At present, I do not accept insurance. I find a cash-based practice works best due to my current schedule. I am currently pursuing a Masters in Public Health and do not have time for additional paperwork. Patients with financial hardship are seen at the community pain clinic. At this point, I am reluctant to engage with insurance companies because of the many problems around reimbursement, paperwork, and administrative details.

LEE LaBRIER-MORTON: The office I work out of already had a system for processing workmen's comp and accident cases. The rest of this clinic's income is exclusively cash. The chiropractor was a provider for insurance but found it to be more trouble than it was worth.

I initially became a provider for Admar and Beech Street, two small insurers that are mostly easy to deal with, about 3 years ago. I became a provider for BC/BS about 2 years ago. For my patients that have a different insurance I provide them with a super bill to submit to there insurance or to use as a health insurance expense come tax time.

In my experience:

1) There is a lot of variation in reimbursement rates for insurance companies. Some do not reimburse adequately for acupuncture therapy and may not reimburse at all for an office visit or consultation. Some do not reimburse for common therapies such as electricity, heat or body work.
2) Reimbursement by insurance companies can take months and often includes several denials before it is all settled. They must be fairly successful at discouraging resubmissions by denying payment since they do it frequently.
3) As a provider for BC/BS it seems that every patient has different coverage. This creates a seemingly infinite number of variables that have to be ferreted out before you know if they are covered for your services and how much of the fee is the patient responsible to pay.
4) It takes a great deal of time to process and keep track of the accounts and paperwork associated with insurance. If the forms are not filled out accurately and completely the first time it can take several phone calls and resubmissions before it is sorted out.

In my opinion insurance is far more trouble than it is worth. However, in a poor state like New Mexico, people often will not get care if it comes out of pocket. Many practitioners are probably like me and became providers in hopes of creating an income they can survive on. Insurance reimbursement is the most expensive and precarious money you are likely to make.

Insurance companies can change their reimbursement rates. If a large percent of your income is based on those rates you may find yourself taking a large and unplanned cut in pay.

My policy at this time is for my practice to be ~90% cash and ~10% insurance. Of course that varies somewhat but I want the stability of a mostly cash practice. I do not plan to become a provider for any other companies.

I am not sure what could be done to improve the situation for providers with regard to insurance companies. Most of the problems are encountered by any practitioner, MD or DOM, that agrees to dance with the devil. Some of the problems are strictly because of our less mainstream status and the variation in laws regarding our practice from state to state.

QUINN AKIRA-TAKEI: I do accept insurance. Currently I am only a provider for Blue Cross and Blue Shield. I am in the process of becoming a provider for Landmark Insurance which services Cimarron health plan and from what I understand will soon be involved with Lovelace insurances. About 1/3 of my practice is via insurance payments. However I expect this number to increase. I have only been taking insurance for about 2-3 months. I intend to increase my insurance paying patients as well as increase the number of insurance companies in which I am a provider. I complete my own insurance claims. It is really not difficult with the right software.

Insurance can be a pain in the ass and has been much more of a hassle than only being a money up front business (which I was for the first 2.5 years of my practice). But it is also advantageous by the simple fact that you will be able to see more patients who otherwise could not afford to see you. If I had to do it all over again I would get on more insurance panels earlier. At least this way you have the option to treat patients with insurance or not.

I feel that insurances need to much more open to practitioners of OM. And many of the insurance protocols need to be changed as well. For example, I feel it is ridiculous that with several insurances the patient must have a referral from a western MD in order to have their insurance pay for services from a DOM. I believe patients should have the power to determine what care they need and who to receive it from. Besides, what do most MDs or PCPs really know about OM??? How do they really know when a referral to a DOM is appropriate or not given the fact the Vast majority of MDs have received zero training on what DOMs do or how they do it. Don't even get me started...

SELAH CHMBERLAIN: I am VP, DeTox Committee Chair, Herb Committee, in practice 23 years, at present in Taos. My practice is distinguished in that I use traditional herbs, combine TCM and my own understanding of Worsley's "5-Element" acupuncture (I started life as a “Worsley-Puncturist” and learned TCM five years later).

I'm not on any “Panels”, but occasionally accept Workman's Comp or accident insurance. I am becoming more reluctant to deal with the hassle. Maybe 2% of my practice is based on insurance and I complete the forms myself. The pitfalls of collecting insurance have been that if they pay CRS, they pay Albuquerque rates and leave me stuck with the additional Taos charges, late or no payment, nitpicking and lying about the forms they will or will not accept. It's hard to know if I would do it differently given the choice.

The current insurance model is based, as is the rest of the country on $$$ rather than needs, and on the idea that medicine is an industry with each provider a factory with its interchangeable parts, processes, and bureaucracies. Some DOM's/acupuncturists seem happy to adapt to this model, others don't, can't or won't. The insurance industry, given the predominant culture, is very unlikely to change its orientation favorably, so I'm not real optimistic right now. Many acupuncturists, especially in California and active in professional politics, are eager to drop Traditional Medicine and its orientation in favor of an insurance-friendly industrial model, and that may be what happens to Oriental Medicine in the next ten years.