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....