Getting Started With Insurance Billing for Acupuncture

All insurance companies will use the same application—the Council for Affordable Quality Healthcare (CAQH)—to verify your qualifications. This entire process is slow, and persistent follow-up is key. It is important to document every interaction that you have with the insurance company, specifically the insurance representative’s name that you spoke with and a reference number for the call. Be diligent and follow up at least twice a month.

If you’re not sure which insurance companies will be the most valuable for you to partner with, think about the population you are most interested in servicing and consider the dominant employers in your area.

Reach out to a colleague to find out which insurance companies they benefit from being contracted with. You may also want to contact HR departments of corporations in your area as well. If a large percentage of your surrounding area is insured through Medicare or Medicaid, consider joining those panels. We also recommend researching which insurance payers have the most competitive reimbursement rates in your area.

A great resource to find the usual, customary, and reasonable (UCR) rates paid for specific CPT codes in your billing zip code is Fair Health Consumer. Their website will show you In- and Out-of- Network rates for any CPT code you search for.

One mistake new providers make is enrolling in too many panels right from the start. We recommend starting out on the panel of only one or two insurance companies so you can have an idea of how much time and work you will need to commit to billing.

In order to verify your patient’s benefits, It’s best practice to ask your patient for a photo of the front and back of their insurance card as well as a copy of a photo ID. To verify a patient’s insurance benefits, collect their name, birthdate, and address. You’ll also need the subscriber’s name, birthdate, and social security number. The policy subscriber may be your patient, but it also might be their spouse or parent. Lastly, you’ll need the plan name, member ID number, and phone number for providers. 

When you verify a patient’s insurance policy, you may find that a prior authorization is required. Insurance companies will often request a referral from your patient’s primary care physician, current diagnosis, planned treatment services, and medical information about your patient to determine medical necessity.

There are many reasons a claim may be denied. If you receive a denial, review the explanation of benefits (EOB) or electronic remittance advice (ERA) to understand the denial reason. Some common reasons acupuncturists receive are the procedure isn’t covered, is considered experimental, or the ICD-10 code used isn’t covered.