Financial Freedom is just an Envelope Away

When I first began working in the finance industry prior to becoming an acupuncturist, I worked with a financial planner whose approach to money management was rooted in the principles of Debtors Anonymous.  Its precepts espouse mindfulness, living on a disciplined budget, incurring no further debt.  Pretty typical for most folks who follow Dave Ramsey or Suzy Ormand's philosophy.  What perhaps separates the DA program from others is the insistence that pleasure and savings must be included in your spending plan, and that as you pay down debt, you don't just roll over the additional cash flow to paying down your next vendor, you in fact spread the wealth to your other categories like vacation, hobbies, savings, educational goals, with an eye to never incurring more debt.  In short, it focuses much more on creating a LIFE as opposed to eliminating debt.  

I have fundamental issues with many of the financial pundits because their focus is on eliminating debt as fast as possible, with not enough attention being given to creating a meaningful budget that can be sustained LONG TERM.  It is almost as if the fact that we have incurred the debt means that we have to wear the proverbial hair shirt and live a Spartan existence devoid of pleasure and beauty until we are debt free and earn the right to have joy in our lives again.  

All work and no play makes Jack a dull boy.
(Remember what happened to Jack Nicholson in The Shining?  Exactly.)

But all work and debt repayment ALSO makes Jack a whim based crazed shopper, leading to impulse purchases and buyer's remorse.  An emergency fund of only $1000 (another Ormand/Ramsey rule) even for a single person is ridiculously small.  (4 tires, a canine UTI, and an unexpected new windshield last year took care of mine last year).  

As a small business owner (firmly steeped in the principles of DA) I didn't know that to begin a business requires capital and that in fact 5 years into my practice I would have over $30K in business start up debt.  Stuff happens, clinics fail or move, cash flow is dicey the first 5-10 years, economic down turns happen.  In fact, I was my own worst enemy in terms of self-flagellation with regard to carrying business debt.  But being steeped in mindfulness in spending, once cash flow was established, those balances were put on automatic payments and basically forgotten about.  I turned my attention to cash flow and creating wealth and in order to do that, I had to include a basic principle that is overlooked by most of financial planners: PAY YOURSELF FIRST.

You are more important than your credit card (or other kinds) of debt.  You, your family, your life.  And in my experience, an eye to wealth creating brings in more wealth.  I had to take my mental focus OFF the debt repayment, and I keep those payments low enough to PAY MYSELF FIRST so that by the time I paid off all my start up debt, I also had a decent amount in savings (which then got used during the downturn in 2009 and 2010, so grateful I had it). 

I didn't start this practice until I had been in practice at least 6 years, and I wish I had done it sooner.  Things are often sporadic in terms of cash flow in a new business, and I tended to squirrel money away in fits and starts rather than in a systematic payment. Things really changed when I started paying myself on the first with an automatic draw into my savings account.  And while it may sound crazy, somehow there was always money remaining at the end of the month even though I took out a chunk for myself and the IRS. This was my first step toward wealth accumulation.

Somewhere in this process, I had the great good fortune to read a book by 
Dr. John Di Martini, noted author and new-age philosopher of sorts, which lifted the emotional charge I had to my business debt years ago and changed everything.  Instead of castigating myself for the CC debt I had engendered starting my business, I needed to reframe how I saw the credit card companies.   These companies (namely Citibank, Chase and MasterCard) were in fact my investors:  they believed in me enough to supply me with the capital I needed to grow my business at a time where no one else would. 

Now you can be cynical about these companies and complain about interest payments, etc. but the fact of the matter is that new business owners do not qualify for business financing through the SBA unless they have been successfully turning a profit for two years and have at least 50K in capitol reserves.  Sorry, but if I had that kind of operating capitol back in the early days, I WOULD NOT NEED THE CREDIT CARDS.

The fact is that Citibank and Chase loaned me that money, and this simple change in perspective allowed me to stop blaming myself and feeling guilt.  I shifted my focus to gratitude that I had been able to have that capitol when I needed it, and gratitude is an incredibly powerful tool in terms of attracting more abundance.   I took advantage of teaser rates and balance transfers as I paid down the balances, but I took my focus OFF the interest I was paying and looked more to creating a sustaining and meaningful budget which supported my life.  Even now that all that is long since paid off, my budget hasn't really changed much in the last 5 years, since my basic needs are being met (I added opera lessons).  Now my attention has turned to long term savings and repayment of student loans.  

I have counseled dozens of students, friends, and colleagues in what I call the "Come-to-Jesus-talk-about-money-and-finance,"  and professionally lecture on these principles at the graduate level.  What I have discovered is that almost no one is taught sound principles about how to handle money in a powerful and confident manner.  The biggest mistakes I see in working with individuals and families is under-budgeting in areas such as food, household or lack of emergency fund, and many times trying to pay down debt too fast.

When starting a mindfulness approach to budgeting, I have found the following tools helpful:

1. BUDGET BUDGET BUDGET:   Create a savings and spending plan for yourself which includes categories for every aspect of your life.  Jerry Mundis' book "How to Get out of Debt, Stay out of Debt and Live Prosperously" is one of the best books I have ever read on the principles of DA and creating a spending plan, and you can buy a copy used for $1 at Amazon here. He demonstrates how to create a working savings and spending plan which includes both paying yourself first and disciplined debt repayment.  I include categories like vacation savings, gift savings, beauty products, clothing, emergency, pet, entertainment.
2. Keep a spending journal.  Yes, until you have this down, write down every single purchase for one month. It can be illuminating.  One of my former students was lucky enough that her parents covered her tuition and rent while she was in school. She had basically no financial aide.  She took out some student loan money near the end of school to help cushion the cost of board exams and licensing, and actually ran out of money before the end of term.  I had her go through three prior months of bank statements and list every single purchase.  She came back shocked that she had spent over $6000 going out and drinking beer, a new surf board, impulse road trips, etc.  A spending journal is essential if you don't know where your money has gone.
3. CUT UP or freeze your cards in a block of ice. (really) I rarely make impulse purchases with cash.
4. If you don't have 2-3 months of expenses in savings, PAY YOURSELF FIRST until you do.   Keep your debt payments smaller, and create a cushion.  Once that is established, THEN you can focus on paying down the remainder of the debt.  Sitting in the discomfort of carrying debt is also a crucible of sorts, a means of transformation in itself.  "But what about the interest," you ask.  Fugedaboutit!  At least until you have some savings.  Paying yourself first is more important and sets the stage to avoid future debt. (An exception is if you are over your limit and incurring overance charges.)
5. LIVE on CASH:  If you have trouble with impulse purchases or going over your budget, consider moving to the envelope method in terms of your personal budget.  On the 1st (or the 15th or whatever your pay period is), consider putting cash in envelopes for each of your categories.  I have used this meethod for years and rarely have issues with it.  If there is a month where I splurged on a pedicure, or dinner out, then it may been to come out of another envelope.  If I don't use the money, I carry it over to the next month.   Folks who have big families with kids and pets  also know that unexpected expenses come up with greater frequency so need to allow for that in their budgets.  
6. When it all become too much, and paying down that bill looks never ending, like my student loans do at times, I have to remind myself to stay in the moment.  The truth is I have enough to last me until I go to bed tonight;  I have a warm bed to sleep in and a roof over my head, running water.  It's a good day, better than for many people in the world.  I am one of the lucky ones.  

I had to be careful not to let the budget become a tool for rigidity or deprivation.  This is a plan, not a sacred tomb found in a burning bush. I have made big financial mistakes (especially in business, yikes!), and if I learn from them then so much the better.  My financial mistakes ironically are sources of unbridled mirth when my former students do the same thing, and I like to think that the fact that I can laugh about it now (when I wept about this 10 years ago) is healing of a different sort.  We all make these mistakes.  We are ALLOWED TO.  

Perhaps the biggest difference that I learned in the DA program (as opposed to other types of financial approaches) was that miracles happen when we become clear in our approach to money,  regardless of our spiritual path.  But the miracles I experienced were not rooted in the airy-fairy  "I created my vision board and now it will all manifest effortlessly."  No, these miracles were borne out of hard work, sacrifice, and not a little nail biting.   They say courage is just fear that has said its prayers, well I say AMEN brothers and sisters.  Unexpected windfalls and cash flow happened sometimes in the nick of time, and sometimes things got paid off even sooner than I had budgeted.

For me, moving to a minimalist lifestyle includes an exploration of what is meaningful to me and creating a life that supports that.  It seems that financial clarity was part of that journey even before I started giving stuff away, so I am curious to see how this may change in the future as I strive to simplify further. 

From the Trenches

I have renamed my blog to what was always my dream title, and is also the fantasy post-graduate lecture series for other acupuncturists.  

From the trenches?  Is this a war, you may ask?  

Yes I think it is. 

A war of hearts and minds being wrested away from the dependency fostered by an unscrupulous and for-profit medical system. 

A war away from the misinformation generated by direct marketing to consumers from the drug industry, creating a generation of patients who think that everything can be cured instantly by one little pill without any effort on their part to change things.

 A war of beleaguered and often impoverished practitioners who dearly love their clients, but are drowning under the weight of oppressive student loans and the energetic demands of trying to support their clients while averaging $40 for an office visit.  

A war against for-profit acupuncture schools who think nothing of raising their tuition to the maximum allowed under federal law every time the federal government raises the lending limits available to students, but refuse to teach them how to successfully run their businesses.

A war against our own resistance to running professional practices including insurance and workers compensation because no one has stepped forward to show you how it can be done.

From The Trenches has been simmering on the back burner for years, and is nearly ready for being launched in a bigger way.  Stay tuned!

What Price Compassion?

I had a conversation with a neighbor last night that left me so angry I couldn’t sleep and got me thinking about the nature of compassion in the health profession. My neighbor said that practitioner A was more compassionate that practitioner B because they charged less money. Unfortunately for my neighbor, I went bananas (apologized later) but it really hit a sore spot with me.


I found myself on the soapbox about the difficulties of practice, and defending my colleagues even though his comments really had nothing to do with me, and they didn't need defending. And since we are never angry for the reasons we think we are, it got me thinking about WHY I reacted so strongly to his assertion that a doctor’s compassion could be measure by the difference in charging $15 and $30 dollars.

Why IS compassion in our society is measured by how much someone charges? And why is it the expectation that the serving professions such as doctors, nurses, clergy and teachers, to name a few, are expected to do this at the cost of their own financial well-being? As if wanting to serve and help others also implies that we must do this at our own expense? Where did service and poverty become linked?

As a long term clinician who has gone through multiple levels of transformation regarding my practice and those I serve, this is something I have given a good deal of attention to. Being in private practice is hard and expensive, and in my experience those who are able to stick it out for more than the first 5 years seem to be able to continue by beginning to put limits on how much they give away, or perhaps to recognize their own depth and knowledge. In the beginning, I wanted to be one stop shopping – a place where patients could get a lot of what they needed or at least be directed to other practitioners who could serve them as needed. And in order to further develop that expertise, most of us continue with post-graduate work, advanced degrees, and trips abroad to study with learned scholars, all of it unpaid or without compensation. After a decade or so, many of us have a depth of training that far exceeds anything we learned in school, in whatever modality – MD, chiropractic, massage, energy healer, therapist.

After about 15,000 patients visits, I realized that the need, the suffering was unending –the well was deep; it will never be done, no matter how much of myself or my personal life I sacrifice, so I better find a way to create a vision for my practice that was more sustaining, that does not burn me out, and that allows my inner child to have the freedom to do other things besides practice medicine (such as go to Italy or study opera).

Master Usui of the Reiki path in Japan found this out painfully after several years of trying to give away his energy work for free. He found that unless there was an energetic exchange on some level between the patient and the practitioner, many of his clients did not get better. And although it was a difficult change for him, he began to charge for his services. The question of how much to charge and what to include for that charge is a personal one, and a doctor’s compassion cannot be measured by that alone. But I think it is impossible to work at a deficit forever – you cannot constantly give and give without having being replenished in some way, or you will burn out. I find it heartbreaking that so many of my colleagues are leaving the practice of medicine forever in search of greener pastures. This is a tremendous loss – it means we have younger, less trained clinicians available to serve both patients or as mentors to younger practitioners.


While I feel guilty that my neighbor got the full force of my feelings on the subject, he also did not realize how truly expensive it is to practice medicine, or the amount of sacrifice involved. I don't think compassion can be measured by something so trivial as what we charge for our work, especially in light of an HMO culture that has become accustomed to a $10 co-pay.  Do you realize the fee schedules for ancillary services such as chiro and acupuncture have not gone up at ALL in the last 22 years and in fact have been reduced in most cases.  Many of us stagger under the weight of 6-figure student loans.  Mental health and massage are now not even covered benefits for many insurance holders.    

In some ways, charging what you are worth is perhaps more a measure of learning to have compassion for yourself in addition to your patients.

What is your goal for treatment? 

How quickly would you like that to be accomplished?

This is a question that we really should ask every new patient who comes through our door – and usually the answer seems obvious enough:  “Fix X as quickly and as easily as possible.”  

It is my role to support and enhance a patient’s treatment  goals, and within the course of treatment to lay down a blue print of balance in the body in order for healing to occur.   In my role as supporter, in addition to acupuncture, moxibustion and massage therapy, I may offer suggestions that, in my experience,  will often speed up the process.   This may include suggestions for chiropractic care, deep tissue massage, dietary changes, supplements or herbs.  A patient is never required to follow these suggestions,  however it may be impossible to meet their treatment goals within the desired time-frame without including them.   These recommendations are made based on over 25 years experience o of training, working with other patients, and treating my own injuries. 

The truth is I facilitate a healing process that is already trying to come forward into physical expression - yes, the body WANTS to be whole and in balance.  That IS its natural state.  My job is to try and remove the blockages that interfere with that process.  That’s it - notice the emphasis on “try.”  I didn’t say I can.   I make my best effort but I think many patients do not understand the impact that their day to day choices have on their bodies ability to move forward into a  healthy state.   This is partly because often, those day-to-day choices don’t show an immediate effect.  Many times the effects are gradual and cumulative (e.g. years of not stretching or having massage work leading to chronically tight muscles which then don’t heal  after a car accident.)   Because patients  don’t realize it, their medical providers often receive take blame.  It becomes our fault that “Condition X” isn’t resolving in the time frame they want.  

A patients timeline to recovery depends on so many things which are out of our control:  how serious is the injury, how long have they had it, diet, lifestyle, attitude, psychological fitness, unresolved unconscious anger or other aspects of psychological or spiritual wounding, use of medications and just plain old genetics to name a few.  In truth, what I actually have control over is where and with how much skill can I put the needles (or moxa or use my hands).  In fact, that might be the ONLY thing I have any control over, so at  in my case I strive to do it well.

Ultimately, I have absolutely no control over the time-frame  of the healing process, and in truth neither does the patient.  While it may be true that their positive actions with regard to their state of health will many times shorten that journey for them, at the end of the day it is really up to something bigger than both of us.  Sometimes a patient gets better in 3-4 visits, sometimes they don’t in 300 - 400.   Sometimes they die. 

My sensei reminds us to treat to the best of our ability, but to try to let go of the results.  This is found in every tradition on the planet – the notion of surrender to something greater than ourselves.  Daily, I try to offer my service in the hope that it will be for their healing, in whatever capacity.  Sometimes it is as simple as their sciatica or headache goes away, but sometimes it is to render aid and comfort as they prepare for the next stage of their journey, whether that is surgery, childbirth, or death.

One of my favorite clients passed away a few year ago, and I saw him on and off for about 6-7 years.  In the early days, since he was a very active senior (still digging ditches in the basement in his late 70s), so he would come in for periodic symptom relief of back pain and sciatica.  After he fell off the roof of his house and was seriously injured, he declined rapidly:  his eyesight went, his heart condition became more serious, and he came in more frequently. By the last year of his life he came in about twice a month, and while I felt sometimes powerless to help both his physical decline, and his corresponding depression at the loss of his independence, I also noticed that while he was here, I would hear peals of laughter coming from the rooms as my staff worked on him, he would play with my dog, and he would  grumble on EVERY VISIT about the out of pocket expense of the acupuncture.  However, he would leave chipper and in a much happier state, more steady on his feet and with a much brighter countenance.   I, however, tried everything in the book to try and relieve his pain, would beat myself up about missing this, or that, since it seemed like no matter how much we did, it was not enough. 

I did not find out until his son called to tell me of his passing that he lived for his visits in the office.  To him, it was much more than medical care – it was  a social outlet, a way to reconnect with the outside world.  I never knew he felt this way because on the outside mostly we heard grumbling about the cost.  It was a reminder that we never really know how we are helping someone, or if we are helping them at all. 

We become so goal oriented about a certain result, that we miss the fact that simple touch, a hug, or a shared laugh together is ALSO part of the treatment, and often a more important part of the treatment.  

That the powerful play goes on.....

Thank you Uncle Whitman and Robin Williams for the reminder. 

They always say hindsight is 20:20, but looking back on my motivation to return to graduate school in my 30s to study oriental medicine, I didn't know what I didn't know.  I didn't understand the heartless for-profit nature of the healthcare industry, human nature, or what it meant to care for the sick and the toll it takes on your own psyche over the years.

Being completely naïve about the nature of both patient care and the health industry in general, it was a vision that was doomed to failure on a number of levels.  I didn't know that I would be entering a field that was vastly under compensated and undervalued for the role it plays in the our current healthcare system, or that I would spend 50% of my time wrangling with insurance companies, or writing reports to justify a $25 payment, or dealing with patients who wanted my services but frankly didn't want to pay for them. I hadn't known prior to becoming an acupuncturist that a net income of $40K was considered wildly successful, but that the $122,000 student loan burden would take about 1/4 of my take home pay.   And I didn't understand the role childhood wounding plays in the doctor-patient relationship.   

All I knew when I started the program was that I wanted to help people naturally, and to help prevent the level of physical suffering that I had experienced after 5 car accidents and some serious autoimmune issues of my own.

Fast forward 13 years, and the learning continues.  We cannot give from an empty place in any capacity long term without it sucking the life out of us.  While this may not seem the same as a "soul-sucking" job in corporate America that you hate, for most of us, Mother Theresa aside, there needs to be a way to restore and replenish ourselves or at some point our lives will implode, either physically or emotionally.  The reasons you become a doctor (or caregiver of any sort) are not the reasons you stay a doctor.  

Personally, this came to head on a trip to Paris six years ago (finally Paris!), when I realized that while financially I had achieved an income level that was now meeting my needs adequately if not lavishly, I was more unhappy than I had ever been.  The toll of working 70 hour weeks for the prior decade to finish school and begin my practice, to serve people 12 hours a day in physical, mental and emotional pain while barely earning enough to pursue my own dreams was huge.  In short, I was bitter, angry and resentful of clients, and exhausted with the pressure of being "on" and positive, a health cheerleader of sorts, when inside I was living a life of quiet desperation.  I was in the throes of what I now know, many years later, as care-giver burnout: something which seems to happen in every field of constant one-sided giving (clergy, teachers, social workers, parents, doctors, nurses.... the list is endless).   

I had finally reached a level of professional competency in my business that I THOUGHT was the magic ingredient to happiness, and in fact had simply substituted a new set of problems for the old ones.   What happens when you reach the seemingly impossible carrot, and you feel worse than before?  Or worse yet, there is a new bigger carrot that I am supposed to want (home ownership for example).

Something had to change, and evidently that something was me.  

This has been a long journey, and one I could not do alone.  After wallowing a couple of years being pretty stuck, masking my pain, and suppressing with whatever tools were available (TV, netflix, shopping, outings, food, wine), thankfully I hit a limit.  I was smart enough to enlist the aid of people smarter than myself to help get me unstuck.  Change is difficult and it is infinitely easier to get support while making big changes - and since I seem to be on the short bus, it took a village (and still does):  a new therapist, a couple of great acupuncturists who are soul sisters, a dog, a beloved mentor and sensei in Japan, and a small group of passionate and dedicated colleagues in the Japanese acupuncture community that have become a second family.  

The last 5 years were a difficult and yet rewarding time of resetting boundaries (no easy task for a bleeding heart caregiver), raising prices, practicing forgiveness in all my affairs, travels to study with people smarter than myself, and allowing myself to be gently dismantled and reassembled.  It wasn’t pretty, as my team will assure you, but I feel like we might be getting somewhere at last.  We see the rewards with new patients, new skills learned in Japan, a more clear sense of " Ok this treatment is complete" (thank you, Sensei), new students who actually want what I have to teach them, and a group of medical doctors who find value in our work at the clinic and refer clients who might otherwise never seek help.  

Alas, I still seem to be stuck at the crossroads of work - life balance.  Perhaps my explorations of minimalism will be part of the equation.

What I wish I had known bout starting a business....

To all my beloved students and former students stuggling with the ups and downs of starting their own practice, read on mcduff! Awesome article completely true and courtesy of Gretchen!!

11 Things I Wish I Knew When I Started My Business

A lot of people like to fool you and say that you’re not smart if you never went to college, but common sense rules over everything. That’s what I learned from selling crack. -Snoop Dogg 

My name is Stephanie St.Claire, and I am an unfunded entrepreneur. I’ve been in business for 3 years, after engaging in my own personal and tenuous renaissance (uh…divorce) and rediscovering my Divine Core Purpose. In other words, I grew a pair of ladyballs and started living the life I always wanted to while making money doing it.  But there was a LOT to learn, and some of those things weren’t covered in Who Moved My Cheese.

Finish reading this wonderful article here:  https://medium.com/i-m-h-o/3dc264023df5

From The Trenches: Part 3

1)     If you decide to accept insurance, put some office policies in place that you stick to without fail.  I lost a great deal of money deferring to patients who insisted they had coverage and then walked out on unpaid balances because I had not verified coverage prior to their first visit.   Now, in my office, regardless of the amount of coverage my biller determines,  it is the office policy that patients pay in full the first visit or two in full until we receive back the first EOB (Explanation of Benefits) and see what their insurance pays.   We don’t know WHAT a carrier pays until we bill it the first time.  Often times, even if a patient has met their deductible, a carrier will find a reason to find some reason to deny a payment or two.  If a patient argues with me over this point prior to the first visit, then I refer them to another provider.  Period. 

2)     Consider using an ABN for balance billing.  An Advance Billing Notification is one way to not only protect yourself from unpaid claims, but allows the patient to determine which additional services they want for their session and to bill accordingly.  While some acupuncturists who practice community acupuncture or more of a TCM style, an HMO fee schedule may be fine. But how do you reconcile yourself to $40 for a 5-elemental or Japanese style acupuncture which usually is a longer treatment, 2-sided treatment, involving moxa and fukushin?

The truth is, you don’t.  My own acupuncturist said it best: “I am sick of filling the holes in the US health care system and not being compensated for it.”   In truth, many of us are practicing far beyond our original scope of practice, becoming primary care providers, including counseling, ordering labs, nutritional assessment, massage, managing toxic drug reactions and poly-pharmacy, and herbs that  we learned at the post­­-graduate level, well outside school.  90% of this is NOT included an HMO or PPO fee schedule.  The ABN was what allowed me to finally accept some of the HMO based fee schedules and build an a la carte practice.  Many of my HMO patients opt for higher copays to enjoy the benefit of Japanese style moxa, massage, or nutritional assessment, none of which is covered by their HMO.  I let the patient decide what aspects they wish to pay for and treat accordingly. 

When all else fails, remember a few things -

1)     You will make mistakes that cost you money, sometimes quite a bit.  This is a PRACTICE – you will learn as you go.  Sometimes you have to pick your battles.  No amount of money is worth my peace of mind any more and the longer I am in practice the better I get at letting this go.  Nothing, in my experience, uses up the desire to serve more than doing it constantly without compensation (thus living below the poverty line). 

2)     You will not get paid on many cases.  At this stage in my practice, the reality is that I write off a few thousand annually in unpaid claims, due in part to mistakes, unscrupulous companies and their practices, and clients who skip out of payments.  I won’t deny that this has been a difficult journey, saying c’est la vie to a case when I don’t get paid, but I get better at it every day.  Releasing the bad case opens me to the next client who pays fully and gratefully enjoys all that I have to offer. 

3)     Billing is a SERVICE which you are not obligated to provide.  Many of my patients pay my full fees, regardless of their coverage and I bill for them as a courtesy, particularly if their chief complaint in internal medicine or fertility and we know a carrier will not cover treatment.  For carriers who are problematic, I issue a superbill and let them deal with it.  In the end, the patient has a relationship with the insurance company, not me. 

I have learned that patients have no understanding of their own insurance coverage.  Southern CA where I practice is the most heavily infiltrated region in the country with regards to HMO coverage, and there is a great deal of entitlement on the part of some patients who have been lured into thinking that every aspect of their care requires nothing more than a $10 co-pay.  They have little understanding of the time, effort and hassles associated with trying to bill for their care.  That is fine, but I no longer feel obligated to provide this service for free. 

As practitioners, it is vital to protect ourselves from resentment, whether from clients or insurance companies.  Resentment is an emotion that eats away at satisfaction, regardless of clinical success.  Most of us are extremely idealistic and altruistic in their regard to helping patients achieve wellness and it can hurt when some patients have no more commitment to you than a copayment. 

I have learned to set boundaries that protect both my cash flow and my piece of mind, and it has ultimately resulted in both more joy and financial abundance in my practice.  My hope is that more of you will take the plunge into the insurance maze, with the hope that both your own practice and our profession prosper both medically and financially.

From the Trenches: Part 2

Lest you feel dismayed, there is light at the end of the tunnel, at least in terms of insurance billing.  I would like to share a few tips, and some of this is obviously hindsight, which can be summarized in a few points: 

1)     Take a billing class ASAP, as soon as you graduate if not before.  Why this was not discussed in my practice management class is beyond me, and I lost 4 years tying to navigate this maze blindly.  This is something I tell my students as soon as they are licensed:  regardless of whether you plan to take insurance or not, at the very least you need to know how to code a super bill, how to discuss claim forms with clients, how to phrase things so that your clients will be reimbursed and how to discuss diagnosis codes with other clinicians.  Forget about being an intern and “We don’t make a western Diagnosis.”  You must learn how to make a western diagnosis in order to participate in the medical system and since most clinic time is focused on TCM pattern differentiation, learning the ropes of effective coding will save you about 5 years of pain and thousands of lost dollars.  The changes coming next year with the new ICD-10 codes will make taking a new billing class mandatory. 

One lesson I learned the hard way is that I simply don’t code for internal medicine.  I have found that many carriers try the “Acupuncture for this diagnosis is considered experimental.”  In truth, 100% of my clients have pain, whether musculoskeletal or headaches.  I may code for additional issues so that I am in compliance with my charting, but my #1 issue will always include pain of some kind.  Period.  If the patient comes in with another complaint, particularly fatigue, endocrine issues, etc.  It opens the door for balance billing to cover aspects of the treatment associated with their other condition rather than for pain. 

2)     Consider using a free electronic billing service such as Office Ally, again not discussed in my practice management class, but will be addressed in a billing class.  I actually did not begin to use them until this year, when I opted to be in net-work with several HMO based fee schedules where the remuneration was so poor that it didn’t make sense to have my biller do the case.  Office Ally has some amazing features, not the least of which is that if you have an error on the HCVA form it will not be accepted for the batch.  I have only had to rebill a few cases with this amazing software.  And, as I said, free for the user.

3)     If you have an expanding practice, consider hiring an insurance biller sooner rather than later.  I waited too long for this step and so did several of my colleagues. In fact, most of my colleagues wish they hired a biller sooner.   What I did not know at the time is that I only have a certain amount of qi, and if I am wasting 15 hours a week trying to bill $25 than this is not an effective use of my time.  Better to use my talent in generating income (e.g. treating), and let someone who is an expert in terms of billing navigate that.  A biller brings the benefit of being current in coding and HIPPA changes that we may not know about as solo practitioners.  In addition, a professional biller is far more knowledgeable in verifying insurance, finding the loopholes, hidden deductibles, etc.  This has saved tremendously in terms of billing cases where the patient in fact had no coverage.

Be advised, billing for ancillary care such as acupuncture is DIFFERENT than billing for western medicine, and a biller will have their own learning curve in terms of billing for acupuncture,  It took my biller and I about a year to work the kinks out – who required chart notes, who was most likely to deny payments, wait times, etc.   It was admittedly scary that someone was now getting 15% or more of the take, but my own acupuncturist found that when she hired a biller, the service paid for itself in a few months. 

As your qi is freed up from the drain and frustration of billing, it becomes available to treat the new clients who are waiting.  My own practice expanded about 30% after I hired a biller, sort of an if-you-build-it-they-will-come scenario.  Had I not had this billing relationship in place, I would not have been ready to see such a high volume of patients.    

4)     Don’t get greedy.  This was a great piece of advice from my beloved chiropractor prior to billing my first Workers Compensation case.  He said “ Don’t get greedy, don’t over code.”  His advice to me was to never code for more than three procedures in any one visit lest you run the risk of being red-flagged by the insurance carrier.  I have seen some acupuncturists bill PI cases at over $400 per session since PI still tends to pay at 100% of the fee schedule for a period of time.  This is completely unethical and depletes the patient’s med-pay, to say nothing of creating bad impressions for us within the industry.  Chiropractors are reaping the rewards of greed and over billing now so let’s learn from their mistakes.

From the Trenches: The Case for Billing

This is a reprint from an article published a few years ago in the Journal of Oriental Medicine as part of a series on practice management.

From the Trenches:  To Bill or Not to Bill Should not be “The Question.”

I was dismayed to see a recent article in one of our professional journals discussing the pros and cons of whether acupuncturists should accept and bill insurance, a topic of some discussion when I was in school over a dozen years ago.  At that time, the reigning consensus was that cash was king, and most wanted to be a cash-only practice, under the radar so to speak, without the hassles of paperwork and coding. 

As romantic a notion as that was then, after practicing for almost a decade, I would venture to say that it is almost impossible to make a living wage in our profession without accepting or billing for certain types of insurance.  A cash-only practice excludes Workers Compensation, personal injury (PI) and certain generous PPOs which have better fee schedules.  Further, I think it excludes us from participating in the medical care system, as exacerbating as it is.   Rather than assuming our proper role along side MDs, DCs, and NDs, we remain second class citizens, medically speaking, often thought of as slightly more educated massage therapists.

In this economic climate, the question is not whether we are to accept insurance and bill for it, but how to do it efficiently and in such a way as to avoid the burnout that frequently drives away otherwise talented clinicians from private practice.  It also requires that we become knowledgeable about coding and speaking with physicians and their staff about how to navigate the insurance maze effectively.  For those of you like myself, who, after graduate school are facing $60-120K in debt, perhaps without additional financial support from a family or spouse, or who have only dabbled in insurance billing before and are somewhat intimidated by the maze, then this article for you.

For most newly licensed practitioners of course, the difficulties and wait times associated with insurance make it difficult in terms of managing cash flow.  My own chronology was that I had a cash only practice for the first 2 years, after which I got my first Workers Comp case.  I think it took me 6 hours to navigate how to even print the HCVA form and line it up with my printer.  OK at that time, my business was slow enough that I was still unacquainted with the idea of  time-for-money.  The fact that it took 6 months and 40 phone calls to get paid was offset by a nice check, although if you include hours worked on the case I think I averaged $4 an hour.

Well into my third year, I began to bill paper claims for some providers, and spent more than 10 hours each weekend doing so, for cases as little as $25,  the going fee schedule for many payers (and sadly still is).  The number of cases that required rebilling was staggering, sometimes for an error as trifling as a misspelled street name.  At that time, paper claims were not processed in under than 60 days, and then add in rebilling and  another 60 days my average wait time for $25 was 4-8 months.  Switching to electronic claims and using a clearing house helped somewhat, but again, lots of rebilling and denials.  Don’t get me started about the hours on hold trying to verify insurance coverage, since most payers at that time were not online yet.  Even now, ancillary care is often not included in the online portion of verifying patient coverage and requires a phone call.

In my 4^th year (and to strains of the Hallelujah chorus) I hired a biller and hired some student interns, and slowly began to get my life back.  But a biller alone did not solve all the problems, since the American medical system and insurance companies in particular, operate with a profit motive which includes unscrupulous practices to deny payment for any reason.  Most medical doctors, unless they run a solo practice, are completely protected from this since they rarely, if ever, have to deal with billing issues.  But for the small solo practice, the nuisances of navigating the insurance billing world leave many clinicians and patients furious and frustrated.   Frankly I was ready to retire by year 5.  

More coming in my next installment....