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....