Office Hours with Angelique and Toby. Released August 12, 2026. 58 minutes.
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About this episode
Insurance billing is one of the most frustrating and financially consequential parts of running an acupuncture practice. Dr. Eoin Gregory of Family Billing Solutions, a retired chiropractor and former educator, explains what practitioners need to know before they sign an insurance contract, submit a claim, or hand their billing to someone else.
He covers when to bill yourself and when to hire help, how to read payer participation agreements and fee schedules, why medical necessity and documentation matter so much, and how to avoid the compliance mistakes that lead to denials, recoupments, or audits.
Topics
From chiropractic practice to medical billing
Why new solo practitioners should often bill for themselves first
Why submitting a claim is the easy part
Being careful with billing advice from other clinicians
Reading participation agreements and fee schedules
Medical necessity, documentation, and audits
A note for listeners: this is a conversation among practitioners, offered for education, not as medical advice. Patient details have been kept general to protect privacy.
Transcript
This transcript was generated automatically and lightly cleaned up. It may contain errors, especially in names and Chinese terms.
Angelique and Toby: All right, everybody. Welcome to Office Hours. We have the pleasure of having Dr. Eoin Gregory with us from Family Billing Solutions. Thanks so much for being here.
Eoin: Absolute pleasure. Thank you for having me.
Angelique and Toby: Can we begin by you giving us a bit of your background? Tell us a little about yourself.
Eoin: Absolutely. So I am a retired chiropractor. I unfortunately got hurt and way back when and prior to doing what I do now, I was in clinical practice in New York. loved seeing patients and working with patients every day. And I was an educator as well. I taught acupuncture students, I taught besides therapy students. So I just absolutely loved doing that. And when unfortunately when I got hurt, I could no longer practice and I couldn'teach anymore. a friend of ours Who owns a medical billing company said, Hey, you know, you should start a billing company because there's a whole group of people who need help that her company was too big to handle, but could really benefit from someone who knows what they're doing and who's made all the mistakes, which is I like to say, we've made all the mistakes. so we started a company. My wife's an acupuncturist, back eight years ago, with the intent of treating practices and treating providers, not treating patients anymore. But with and with that we wanted them to be better and to be awesome and to reach the height that they can or the height that they want to by taking the load off them that medical billing often creates the stress and the all the anger.
Angelique and Toby: Yeah. How many providers, groups do you do you have with you now that you help?
Eoin: We have I was just trying to figure out the other day 'cause it's always in flux. We have about a hundred and thirty providers that we bill across over a hundred companies. A big chunk of those happen to be in Massachusetts, which we happen to love Massachusetts, but I'm a little biased since I grew up there. and then we but we have providers in twenty-eight states currently, so we work across the country And there's also a lot of providers who need help.
Angelique and Toby: Yes, there are so many of us that need help. as I know that you know, but I tried doing this myself because I thought it can't be that hard, right? So I enrolled in a couple of, you know, insurance companies. This is a couple of years ago, and I was like, I can figure this out, I can do this. And I lasted about seven weeks before I reached out to you. I was like, help me, I need help. Because it's not it's not that simple. It's not
Eoin: It's you know it's not that it's not simple. It's just a lot of work. It's a lot of work and there's a lot of organization that goes into it. There's a lot of patience that goes into it. There's a lot of phone calls that go into it.
Angelique and Toby: So many.
Eoin: And I last I heard you were an acupuncturist, not a phone representative. So I think your time is best spent in the treatment room, not on the phone.
Angelique and Toby: Agreed. Agreed. And I didn't realize how much time I would be spending on the phone. I really didn't. I was I was unbelievable. And so yeah, it's been it's been a blessing to have family billing solutions helping out. And but I think you had made a you had talked about before and I think one of the things that's important to get some perspective on is why you think when why you think someone should do their own billing before hiring a biller.
Eoin: I think it's actually really important for solo practitioners, chiropractors, acupuncturists, anyone who's billing to bill on their own at least initially, because you generally have a little bit of a time. You have that time factor if you don't have a full schedule. you also have the chance to take billing coding classes, which are really important because you really need to understand what the codes mean because it has a big effect on your documentation, what you include. in your documentation, what you don't include in your documentation. And it also gives you a perspective on how much work is involved. So if I have someone who's brand new who says, I want to work with you, I say, okay, for example, how busy are you? Well I'm not that busy at all. I said, you need to take billing encoding class and do it for yourself for a little bit. One, because usually they're not generating enough revenue to make it economically feasible for them to hire a biller, unless you know they're independently wealthy, in which case I'll be happy to help. but the other side of it is that experience of understanding how much work goes into the billing process and the actual we say billing, but it's not billing that's the issue. But billing is super easy, you know, submitting a claim, you know, click, claim sent, you know, that's that is easy. And it's it's everything else that's a pain. But it's and it's worse than a pain. There'so many inconsistencies, there'so many battles to be fought. And if you're a provider, You're treat you're you're trained to treat patients. You're you're trained to help people heal. You'really not trained to help figure out their insurance. And you're also not trained to fight the battle, to fight the fight, you know, file the appeals, you know, call and make get reconsiderations. And it's it was a really big issue in particular in COVID because there were no phone representatives. Everything took an hour, two, three hours to make phone calls. It was it was just an amazing amount of work. And the and so for providers, even though they weren't busy, they just they still couldn't reach anyone either. It was just it was nuts.
Angelique and Toby: Yeah, I can imagine. one of the things that I don't know. So when I as when I came out of school and I took the billion coding course and you know, I knew an acupuncturist, like, well, Toby, your ca your practice is not insurance based at all. And so I had to make a decision. And as a newer one, I thought, well, there's a lot of acupuncturists out in this area. I think I have more of a chance to be viable financially if I accept some of the insurance plans. So I just decided I'm going to take all of the insurance plans and I did. Like ultimately, once you were on board, I started out with a couple and then I took a whole bunch of them. And so when people are coming out of school, like what do you think as someone who's done work in this world, both in our sphere of medicine and in the insurance realm, what do you think's what do you think are some important things for the new folks to be aware of or even folks who've been in practice for a while that might consider opening the doors to insurance?
Eoin: Yeah. There's a lot of things to consider. The first thing is any advice given to you by another provider should be taken with a grain of salt, unless they are some sort of expert. Because I sus I think the biggest issue that we have is providers come on board and they say, Well, so and so is making X number of dollars and this person is making X number of dollars. And w they're being told to bill in a way that's really not compliant and or f technically fraudulent. And that's Big deal for us because we won't do that. We won't we won't bill massive bills just because they're gonna pay it. Because it's it's not ethical, it's not moral, and it's b illegal in many cases. So if people come out of school and they say, What should I do? They should be leery of what their friends and or other acupunctures tell them. They need to take a billion coding class, first off, even if it's a short one, two-hour one, even if it's free or whatever the case may be, even if they should go on some of the websites that are out there. And learn a little bit about it and understand that there's a responsibility when you are billing insurance to meet certain requirements. So that's the that's the first part. The second thing is understanding what a network participation agreement means. What does it mean when you go in network? And essentially it means that you're agreeing to what that company pays for care and also the restrictions of what they don't pay for. And I don't want to go into individual specific insurance companies because that's outside the scope of this, but people get the impression that they can, I can bill a this code and that code and the other code and only to find out the insurance company only pays for four codes, the four acupuncture codes, and they only pay for two units or three units. And so when you get this participation agreement, you need to make sure that the fee schedule's on there because that's a actually interesting. You'll get a whole billing agreement to bill with that. payer participation agreement and there'll be no fee schedule attached. Where
Angelique and Toby: Yeah.
Eoin: Is that? Where is that? That's important. and because and the thing and the other thing is not just the numbers. Say, look at this, they pay this, they pay this, and they pay this. It's the it's a payment policy on top of that. So an insurance company might have fees for exam codes, E and codes, or they might have fees for therapies, but their reimbursement policy might say they pay a maximum of hundred dollars a visit, they pay a maximum, which is not bad, but a maximum of fifty dollars a visit, a maximum of forty one dollars a visit in California. And so no matter what you bill, it might add up to $150 based on the fee schedule. You need to read the details, the individual lines that say, this is a global rate. and I think that's important because they need to understand what they're committing to, what they can't do, and particularly balanced building when you're in network, and also The other aspects is, you know, when you decide if you decide to leave, you know, what your obligations are both to your patients and also to the you know, insurance company. You can't just say, All right, I'm no longer taking insurance. It's there's a time period where you have an overlap where have to continue care and you have to treat these patients, otherwise it's patient abandonment. And I think that aspect and the other aspect is important to know what the medical policy is. What does a plan cover? Because if you're, for example, with a company, not going to pick on individual insurance companies, but the medical policy says they'll cover migraines and chronic tension headaches only. Would it make sense to be a network with that company? No not really, because what percentage of your patients come with migraines and coron chronic tension headaches? And the answer is not that many compared to low back pain or not that many compared to other complaints or you know depending upon if you have a specialty. So that'so that those are things that you really need to keep an eye on because The insurance companies are in business to make money. They're not in business to make providers lots of money. so you so you definitely gotta look at those things. And if you don't understand them, if you're not an attorney, then spend a little bit of money and have an attorney look at them and give you some guidance or some advice because you're making a legal contract, you're signing a legal contract to do something and you have to be wary of what you're doing.
Angelique and Toby: Mm-hmm. That's good advice. And it takes a long time to read those contracts. They're they're
Eoin: My gosh, they're so boring.
Angelique and Toby: So boring. They're so long. It's incredible.
Eoin: So my wife Jessica as an acupuncturist is actually one of the people who reads everything. And I always make fun of her. Are you going to read everything? You're going to read everything. Well, it turns out if you don't read everything, you might miss something very important. And she's caught a couple things that were in the cracks about what certain things that were not covered in. we only cover two units of any given coded therapy or time service. Like suddenly, wait a minute, only I pay for two units of acupuncture. And those types of things of reading the read it down to the details is hard because
Angelique and Toby: Yeah.
Eoin: We're not lawyers.
Angelique and Toby: Right. And it's created for the lawyer to look at, right?
Eoin: Yeah. We wanna know how the cr contract feels, not what the contract says.
Angelique and Toby: Correct. Yeah, totally. so when do you suggest someone looks for a bill or
Eoin: That is a great question and it varies provider to provider, insurance company to insurance company. But this is my advice for anything. When you get to the point where you're losing time to do the things you both enjoy and the things that generate revenue, then you need to consider having someone do it for you. So if you're spending every Friday night until midnight doing your billing rather than having movie night with the kids or you know, going on a date or going out with friends, then it's time to get a someone to help. If you're losing two or three patient hours of care a week because you're doing your billing, then it's time to consider selling it out and having someone manage it for you.
Angelique and Toby: And so when someone is ready to hire a biller and they're not sure who to choose, I mean, I personally would say you. But let'say, you know, they want to kind of play the field a bit. What are what are things to look for when hiring a biller?
Eoin: Well, I appreciate all the love, but I will say that the biggest thing is finding someone who f both feels like a good fit for you and also makes it quite clear what it's gonna cost to work with them. Because we see them saying the company saying we have this low rate, we have this low rate and if but if you don't read the contract and realize well, a low rate, but you pay a certain number of on top of it. so there's lots of little details within the agreement. The other thing you wanna look at is what is billing experiences the company have. You know, there's lots of amazing billing companies that work with all different professions. Acupuncture is a tough profession to bill for, mainly because and Jessica loves to use this expression, dermatology. Dermatology, you're covered. You just go and they you're covered. You know, if but acupuncture you can't just go and be covered. There'so much detail and there'so many little things that are involved with making sure that the care that you provide is paid. And so looking at different billing companies, do they have that experience? Do they have that knowledge? And then the other side of it is that how approachable are they? Was it hard to reach someone? do they answer the phone? will they talk to you on the phone? You know, is everything by email? And I think that For me, every claim matters, which is actually a problem because I then I focus too heavily on claims, but every claim matters because every claim is a unique person's care. And the ability for you to see that patient means that you have to have the care paid for. And if you have a biller who's just looking at numbers, it's like, we have a 1% finale, we're okay, or we have a five percent finale, we're okay. The that doesn'that doesn'translate well to small providers because That could be five percent of your income. That could be more than five percent of your income because a claim is just a number. It doesn't actually tell you how much that claim is worth. And so, you know, for me, it's like you need to know that the person really wants to do it and is willing to fight for those claims to get them paid. And when, for example, the insurance company provides wrong benefits, is willing to do your do the appeals. And isn't ch gonna charge you extra for the appeals? Or if they are gonna charge you extra, how much is an appeal gonna cost? And what level of appeal will they do? So there's all these little things. and I think it's not a problem to necessarily pay for these little things as long as you know what to expect. And that's that's again, you know, you go to buy a car and the car is X thousands of dollars and then you go to the finance and then you realize it's another twenty percent more for all the other add ons. And if you know that's gonna happen, then you can deal with that. But if you go in thinking you're gonna pay you know, X number of thousands of dollars and suddenly now you're paying X number of thousand plus twenty percent. That's a huge difference. That's a huge amount of your practice. So I think one of the biggest things is transparency. How transparent is the company? The second thing is experience with acupuncture billing, which I mentioned before. and also manpower. Is it is it just one person working for herself and does she have help? Does she have a lot of clients and she's overwhelmed and How often is she submitting claims? How often is she falling up on claims that aren't paid right? And there's nothing wrong with the individual who does the billing, except they go on vacation and they're not always available. And those things are important, especially when you're a small provider and someone calls you last minute. my gosh, I put my back on. I need to come in and see you. Do you take my insurance? Question mark. And then the answer is maybe. And let's find out if there's coverage. Is there someone available to do that? And do they have do they have you know that team?
Angelique and Toby: Yeah. I must say that's one of the things that have been really helpful because there's a box that I can check on the website where it says rush. So in that kind of situation, I can check that box and usually someone gets back the same day, sometimes the next day, which has been really wonderful.
Eoin: We shoot for two hours, but some days you just can't reach insurance.
Angelique and Toby: Companies. No, it's it's really awful. I mean sometimes you guys even can't like you can't get through period despite multiple attempts.
Eoin: We've had people hang on hold for five hours. Like so they'll have they'll have their phone on in the background and it's just on hold. And then at a certain point the other company's phone system just cuts the call because it didn't pick up. and it's it's unconscionable that the insurance companies and the payers expect you to provide care, but they don't provide the service that they need to for you to be able to know whether or not the care is covered.
Angelique and Toby: Correct.
Eoin: And that's a that's a big problem. And I hate setting out those verifications that say we weren't able to reach the insurance company. This is what we found online. The exception is when we know the policy, we know the insurance company. And that's the other thing is does the biller you might be working for have experience working with that payer? You know, we send thousands of claims out to Blue Cross Blue Shield in Massachusetts. You know, we know, we know how they work. We know what's necessary. They ha they require you to mail stuff. We know that. Okay. We do a mail run twice a week. We you know, it's those things that you need to know. MassHealth, you have to use our website, which is ridiculously horrible. I'm I'm sorry, I'm not supposed to mention individual insurance companies. But
Angelique and Toby: Yeah.
Eoin: But if you know if you know that system and you have that experience then you can do those things. Yeah. And it's just it's just part of your routine, it's part of your you know, daily plan.
Angelique and Toby: Yep. Toby, I don't want to leave you out hanging. Do have any burning questions? Because I could keep going. Yeah, do you have any leverage on them? like, you know, if you're you're on hold for five hours and they cut you off, is that there's just nothing you can do? You just have to call back, or is it is there any leverage that you have on your side?
Eoin: So the first thing we do is tell the providers to tell the patients that the there's a their insurance is a contract between the patient and the insurance company and maybe their employer. And if we're not able to reach the insurance company, it's they have an obligation to verify their benefits and find out if there's coverage. And if there is coverage, we give them a list of questions they should ask. But if the claim is not covered, we can'take responsibility for it. There's there's nothing we can do. And if the insurance company doesn't pick up and never answers and you see a provider and you submit that claim and it's not paid and you didn't verify benefits, even if the insurance company wasn'there's nothing we can do. Even when they misrepresent benefits, they you get a you get someone at an insurance company, very large insurance company, one of the biggest in the world, sorry, biggest in the United States. I don't can't say world, and their poorly trained representatives provide wrong benefits. and not just one but three people provide wrong benefits because then we'll call back again and check is this right or is this right? there's there's you do misrepresentation of benefits appeal. And I have to say those are successful ten percent of the time. So there's no there's no accountability for the insurance companies. None they none.
Angelique and Toby: I wanna shake my fist.
Eoin: Right here. I'm already shaking it. There's there's no accountability. And that is the f tough part too because providers are accountable to their billing agreement, but the insurance company should also be accountable to the billing agreement. And that billing agreement says that you'll provide care, but also the insurance company is gonna provide the benefit information. And frankly, i acubunction benefits are not available online for some companies. And that one particular company that has poorly trained representatives they don't have accuracy benefits online, which means that we're dependent upon the phone representatives to provide the information. And we have situations where we will call three times and see, okay, best two out of three, which two people agree on what the benefits are. and then we tell the provider list, we've talked to three different people and they told us three different stories and That's the best we can do. Tell your patient because you're the contract with the insurance company is between the patient and the insurance company. So if we file an appeal because of misrepresentation of benefits and it's not successful, the next level appeal is usually a patient appeal. So the patient has to be willing to step up. And that actually is important from a billing standpoint as a provider, because if you are going to be billing insurance, you have to make it crystal clear to your patients that they are responsible for the cost of care. that they're gonna be responsible for paying this bill if their insurance company doesn't pay it because it's their policy and it's their insurance. There'some exceptions like Medicaid plans and stuff, but if they understand that they'responsible for paying for this bill, then when the claim is not paid, the onus is on them to go to try to get paid. But you bill them. Sorry, insurance didn't pay. Here's a here's a bill for the care.
Angelique and Toby: Which is which is at least nice to have recourse in that regard.
Eoin: So
Angelique and Toby: But it'so asymmetrical, right? It'so asymmetrical, right? You provide the care, and maybe you'll get reimbursed or not. That's that just seems like a tough spot to be in.
Eoin: It's even worse than that, honestly, Toby, because let's let's talk about acupuncturists as an example. If we were to measure acupuncturists on a l on a scale of like rigidly following the rules and big softies, they tend to be more on the big softy side. and that's a problem because when you're on that big softy side, you write things off. You don't charge patients, you don'tell patients they owe money, you don't collect what you should collect. And that's because there's a fear of telling a patient they owe you money. And that's a very realistic problem for those of us who are softies. And I will admit that I'm a softie. I love my patients. There are some patients who probably owe me thousands of dollars that I'll never collect because I'm not going to ask for it. And that's a that's a big issue for acupuncturists. So I always say do two things blame the insurance company and blame your biller. My biller says you owe me this amount of money. You know, I don't care. They blame me. But that's why you have a biller. That's why you have someone standing behind you to do this work. Because you can hold them accountable, even though they're not responsible, but you can blame them for the patient owing a balance. my billing person told me that this is how much you owe. Or my board of the insurance company says this is how much you owe based on the benefits and whatever. and but there's no accountability on the insurance company side. the only exception is Filing complaint with the state because they are f not all, but some plans are accountable to the state for the thing. And church companies don't like complaints to the state.
Angelique and Toby: What would warrant a complaint? Yeah.
Eoin: Have I have I done it? Yeah. I can't neither confirm nor deny that I have filed complaints with multiple states on my own when I was in practice on my own. we don't file complaints for providers. We will provide them all the information they need to. in many cases we go honestly, we go above and beyond to get that information to put together or help them put together a letter about what they're what the issues are. And a lot of times. I hate to say it a lot of times insurance companies do not want to look bad in front of the state and they'll like cave right away, or nothing will happen. But it's very important to understand though. These this is insurance that's regulated by the states. If you have a self-funded policy that falls under something called ERISA, E-R-I-S-S-A, one or one s eri sa, these ERISA plans are regulated by the federal government. They're not they're self-funded plans. You complain all you want to the state, it makes no difference because The state has no influence on the insurance company. Mm-hmm.
Angelique and Toby: So what would merit a complaint to a state?
Eoin: I think a big thing would be repetitive failures to follow their own guidelines or own rules. you know, we had a situation where there was an audit. The audit said that the provider didn't do XYZ and their requirements said that this was required and that was required and this was required. And the fact is that's not what their requirement said. That's not what the rule the that's not what the medical guidelines say. And that's the kind of thing that we're That would be if the insurance company is not willing to work with you to go right to the state and say, I've worked with the insurance company, I have done this, I was audited, they took this money back, or they didn't pay me for these claims. And they're saying it's for this reason. But the problem is that this reason isn't legitimate because they don't have this written down anywhere. And it's a lot of work. And for this one particular provider, I have spent 30 hours working with this provider. Now why? Well, two reasons. One, I hate it when the bad guys win. I just can't stand it. I can't stand it. Because I'm here to help providers. I'm I look at I look at our list of providers and I was saying before that we have a directory with pictures of our providers because we are treating providers and practices. They'real people and every claim isn't paid is money that they don't have to pay their people or buy needles or pay their rent or rent at home or I hate to say it, but buy food. I mean, there's there's a lot of issues. Each claim matters. And so taking it to the next level and going to the state is sometimes your only recourse. And we've done it and we've been successful in some situations and we've been unsuccessful in others. And a big part of that has to do with how good the documentation was that the provider had, how poor the documentation the insurance company had was. So there's a lot of variables inside. And if the insurance company is regulated by the state, you know, do they want to have a black mark on their record over three thousand dollars, which is a huge amount of money for an individual provider, but is nothing for an insurance company. Mm-hmm. But that get that actually gets me to another point and I just want to bring this up. one of the problems we have with chiropractors and acupuncturists and such that physic even physical therapy to a certain extent, is that we have to understand that care is subject to medical necessity. And medical necessity is like, well what does that mean? It basically means that you have to treat the patient until they're as good as they're gonna get. And the way you're gonna treat them is an appropriate way to treat for that condition. So it goes there's a lot more that goes into it. There's huge classes on it. I've talked with providers ad nauseum about it. But ultimately, if you're treating the patient every week for fifty-two weeks, I can guarantee the insurance company could come back and say, This is all wellness care or this is all maintenance care. This shouldn't be covered. And that's where both good documentation and being aware of how you're billing is so very important. And in no way do I tell providers that they should that they should make up things or they should do things that are inappropriate, but y it's oftentimes a game that you have to play. That you have to make sure that you're meeting what's called medical necessity and you're actually treating the patient in a way that's appropriate to their condition. And that's tough. And providers, I mean listen, we're big softies and the our healing traditions are not are not one time and done. You know, it's not even a six week course of treatment in many cases isn't enough for what the patients need. Or 12 weeks or even 28 weeks, you know, it just depends on what you're doing. So that meeting the medical necessity is important. And the other thing that providers are really not good at in general is having treatment plans. And the treatment plans are what you can use to help establish that medical necessity. medical necessity is so very important if you particularly if you're you're gonna get audited to say, hey, you're overtreating these patients. The answer is no, I'm not over treating these patients because here's my records to show that I'm not.
Angelique and Toby: Mm-hmm. Which is a lot of work for us on the provider end, I must say, as one who is a bit of a stickler for the rules.
Eoin: It so and this gets into another aspect. So you have a biller who might cost you about a bit of money, but it's gonna save you a lot of money. It might actually save you more than you spent. But the other side is software. If you're taking paper notes, that could that's great. Is you if you're no there's nothing wrong with paper notes, all right, at all. Nothing wrong with them. But if you're using software, your software can provide so many resources. To help you establish medical necessity and speed up the documentation time and speed up the process of getting things done. And you have to invest some time and energy into figuring out what works for you, what works for your practice, what works within the both the profession and also what's required under those CPT codes. And you can have a great source. But it fact the fact is you have to do the work. You have to put it to have to do your notes. That being said, if you have a care that's driven by a treatment plan, Your notes do not have to be wild and crazy. It's it's like how you do when? Are you getting better, getting worse, staying the same? All right, we're gonna continue with the treatment plan and here's what we did for the day and here are the CPT codes. Literally, that's all you need as long as you have a plan in the beginning. And setting that up to be a course is not difficult, but it requires you to pay attention. And it'so hard. You there's no doubt, you pay attention. We know you pay attention. You are the type of provider we love. And the reason why is that you're heavily involved in the billing. And that's another thing. I'll go back to the beginning. It's very important that you have a your biller has a system where you can check on the status of claims. You can read the notes of what's been done. So there's transparency in the billing itself. So this claim was sent on seven one and on seven twenty-eight or eight two, we followed up and this is the status of the claim. It's in process. Or you know, that 30 day mark is kind of like the timely processing period, we're right at that 30 day, 35 days or so. And we have all that information available for our providers. And if you have a biller who's using a system that you can't access and you can't see, your claims are lost to you. You have no idea what's happening. And that's not comforting because you don't know. The and the other thing and I just want to mention this real quick when you're billing you should not be giving your chart note to someone to create an a CPT claim for or create use add CPT codes and then send out a claim form because your claim is representative of your care you need to be explicit in terms of what you did and what codes you want to bill you can't be dependent upon someone else unless they're like a specialized coder who specializes in that and your notes are super clear. Otherwise You're going to end up with two things. You're going to end up with claims with crazy diagnoses. And you're going to end up with claims that are way overpriced because you didn't pay attention to how much was being billed. So there's and there's a couple of factors that go into that is did you help create that fee schedule? I never create I never tell someone what to bill. I always give them a sample fee schedule based on their cash rates and if they offer a time service discount. And that's because it's their fee schedule. It's not my fee schedule, it's their fee schedule and they should know what's being billed. And when a patient gets an EOB and you bill eight hundred dollars for a visit, and I seen it's like how can you justify billing that much when your cash rate is eighty or a hundred or even two hundred? How can you can't justify billing eight hundred dollars with a care, unless you made a mistake. and so that's where owning your claims and owning your that d that level of detail is so very important, and that's where good documentation system can help because you know what you did, you know what codes to bill. You and also that's where good insurance verification comes in because you know it's covered. Right. You know it's not covered. and also just personal experience of saying, Hey, you know what, I just can't bill this code to this insurance company, or someone who's auditing your charges you put in and say, Hey, we don't recommend billing this code because it could flag the claim and you won't get paid. Or, you know, so all of those things play into it. and so they're your claims. You need to know what's going on. And if you don't know what's going on and there's a problem. You're ultimately the one who's gonna be stuck, you know, dealing with it. You know, if there if there's an audit and, you know, the biller's not gonna I mean, they might say, Okay, I'll help you, but at the end of the day, you're the one who got paid. You're the one who did the care, you're the one who did the note and it's your it's your claim.
Angelique and Toby: 'Cause insurances can take their money back down the road.
Eoin: They can take the money back. for the most part, they can'take it back as much as they can withhold. They can withhold the money that they say you owe from a future payment. And whenever you get a request for money back, that'something that you need to get to your biller right away and have your biller look at it and say, Is this legitimate or not? And it this
Angelique and Toby: That feels like a rose by any other name, right?
Eoin: They're not gonna pay you for other precare. But the thing is that is the is the recoupment legitimate? It's it's and now we s we hear all these different terms, clawback and but w the official term is recoupment. They'recouping funds. Is it legitimate? Did you submit a void because you billed the wrong patient on an accident? It happens, you it's just administrative mistake. Or i are they asking for money back because the patient had other insurance that we didn't know about, or the patient, and this is a big one for one local company, Because the patient didn't respond to a letter that was sent to them whether or not the care was related to a motor vehicle accident or personal injury. And that'something that needs to be on your intake forms. Is this care related to a motor vehicle accident or personal injury? Because that makes a huge difference. You can then clearly say the patient reported that this was not related to that. And so when the insurance company says we want this money back, you need to go in your or your biller needs to look at it and say, Is this legitimate? And if it's not legitimate, your biller. should be the one who's doing the work to get it fixed. You shouldn't be the one doing the work to get it fixed.
Angelique and Toby: I just had that happen the first time. Got one of those letters and you guys actually caught it before I did and said, Hey, this happened and so I had to get it.
Eoin: We caught it before you. Yeah. That's that's good. We must have been right on top of things.
Angelique and Toby: He did, you got it before I dead saw and I was because the patient didn't complete a survey. Yeah.
Eoin: That's exactly right.
Angelique and Toby: So they withheld, you know.
Eoin: It's a coordination of the benefits denial and they're right now they're working on like October November of last year. So you'll get a letter saying, you know, this, you know, we're we think there may be other insurance involved. We're gonna take this money back. Yeah. And if you're a solo provider and you're working the office by yourself, you don't have time to call the insurance company, figure out what this means. Right. Figure out why. or one of the other ones that we get every once in a while is in the and this happens, particularly at a network providers, is someone's method deductible And then you get paid the full amount that was for the claim. And then someone else sends in a void or changes a claim and now the deductible is owing again. And rather than taking out a the future claims, they ask the money back so they get the patient can be the deductible. Which means you have to go back to the patient asks for that money. And that puts you in a really tough position.
Angelique and Toby: So awkward.
Eoin: It'so awkward and it's not fair to you, but this is where you say, My biller says that you owe or my insurance company says that you owe this money.
Angelique and Toby: The insurance.
Eoin: Yeah. Yeah. They got thrown under the bus of the expression. Yes. So okay.
Angelique and Toby: What's the most egregious thing you've seen from the insurance companies?
Eoin: So let me let me preface this with saying that I don't believe that insurance companies today are out to just throw papers away. I mean, back in the we were like, well throw every third claim away, but you know, it's everything they wanna do things legitimately, but their systems are put into place to help save them money. So the most egregious thing I've seen, I don't yeah, you know, that's that's a tough question. I think it's I think it's recouping money years later when someone had a personal injury and they had a settlement and the insurance company said, Hey, this person had the settlement for this care and the settlement should pay for your care and so we want all the money we paid you back. And so now you have to go to the patient and the lawyer three, four Or five years ago and say, Hey, you owe me for this care. And you ha and if you didn't know in the beginning and you don't have a document that says they agree to was called a lien essentially a lien on their care, then you're the one who's left paying the insurance company back. And that's that's the insurance company's job is to protect the owners of the insurance company, whether they be stockholders, whether they be the insurers, but it's it puts the providers in a very awkward position, particularly solo providers and small providers.
Angelique and Toby: Yep. Yeah. Yes, for sure.
Eoin: And you get that letter and you want to cry.
Angelique and Toby: I haven't gotten that letter, so thank God yet. Knock on all the wood.
Eoin: You're like this is Blooney. Let me go send it over to Ian's team.
Angelique and Toby: I would I would one hundred percent. Yeah. It's I mean it's it's a comfort as a person that's out there like doing all the things myself to know that I've got a resource or it's like if I have a problem I can like, Hey, help me and you guys do,
Eoin: We do, we try. We try to be responsive. because we have that clinical background and not just that the practice background, I can provide practice guidance, not because I'm some practice guru. Because I made those mistakes. I did that. I d I did exactly what you're doing. And I'm gonna tell you, hey, you shouldn't do it, you should do it this way instead. Or hey, you wanna make sure you have this form, or hey, you wanna make sure the patient signs this. hey, you wanna make sure you don't do XYZ because we've done it. We made those mistakes and we were practice. We started a practice during the recession. we survived. and then of course, unfortunately I got hurt and had to figure out what to do with my life. And I love people, I love treating I love treating people, so let's treat practices.
Angelique and Toby: That's really a lovely way to look at it. It is.
Eoin: We want you to feel like you're hiring like your cousin to work for you or your aunt to work for you or even a family member to work for you, that you trust they're they're out for your best interests, that they're they're they're there not to slack off and not do their job, but they want you to be genuinely s genuinely want to be you to be successful in practice. And that's that's hard in a corporate environment and a even a small company environment to maintain that. And you've experienced this. We've we've actually we made a mistake and we made it right.
Angelique and Toby: You did.
Eoin: We made it right. And we've made it right because it was our fault. And I'd say this to my kids all the time, my kids are little bit older, said it's not about right or wrong. It's about who's gonna fix the problem. And yes, there's a certain amount of responsibility that's there, but yes, there's a certain amount of work you can do. But if you make a mistake, you just accept responsibility and deal with it. And I would rather deal with and fix a problem and maybe lose money or pay back money or whatever than I than lose someone who's valuable to me as a both in an individual as a and as a business and as part of my business in terms of my revenue. Your patients are important because they help you live, but they're also important to you because they're like your family or extended family. that you want to know. You've you particularly when you're in practice a long time, you watch them get married, you watch them have kids, you watch the kids go through the years and graduate high school and then graduate from college and you realize that you genuinely love these people. They've been with you for a long time and you don't want to have to say, I'm sorry I can'treat you anymore because you I don'take your insurance or hey I don't want to I can'treat you anymore because you're out of benefits. But I will say at the same time, those people want you to be successful and are willing to pay you. People are willing to pay you. I d I don't know why we're suffering such big softies.
Angelique and Toby: We I we are. It's and Toby's been really helpful in helping me be soft in the right ways, not in the like give everything away for free ways. it's it's hard because I you know, I can I can relate to that. And I think one of the harder things that happens is regarding medical necessity where you have somebody that has an insurance but it only covers low back pain and they want to come in because they have menstrual pain. Or you've got someone who just wants to do wellness care and then zero percent of insurances cover wellness care. I mean, I know if it's zero percent, but I haven't seen one that's just like, you can come in for anything you want. and having to have that conversation, being like, you I would love to treat you. I just can't bill your insurance for that. And I've had folks get angry with me as if I'm, you know, well, I had another provider that did this and that and the other thing or You know, isn't Chinese medicine whole person care? And it's like, absolutely, Chinese medicine is whole person care. And I will be treating all of you. However, we need a clinical focus that is based on what your insurance will pay for covering. So if that's neck pain, then we have to be focused on your neck pain while we also treat the entirety of who you are. And I have had people who get very upset. And I, you know, it's this is the insurance rules. And I'm not, you know, I've had folks actually and un they didn't ask directly, but essentially what they were asking me for was to commit fraud. You know, to be like, well, just bill for this and do what I want, you know, or just say that I that I have this. And I'm like, I am not, I'm not doing that.
Eoin: It's it's even it's actually even worse than that. in the sense that let'say the insurance company only pays for low back pain or neck pain and the person's coming in for something like a knee pain, all right. Now maybe their back hurts, okay, then they legitimately have some back pain. But if someone has a condition like for example, back pain and you treat it, then you're great. But if someone doesn't have back pain and you diagnose them with back pain, they now have that diagnosis for the rest of their lives. It's in the system. And don'think that once that insurance company knows they have back pain that every other insurance company doesn't know as well. Prior to me becoming a chiropractor, I worked for a life insurance company. And one of the things we did was we looked at insurance records and said, Hey, this person got treated for this condition, but they didn't document that condition at all. So we were not going to cover them because they had this low back pain, which they really didn't have. So or we're not going to insure them because or we can't give you this job because you have back pain and This job requires you have a strong back. So there's all of these things that you can do negatively for a person by treating them in a I don't want to say sketchy kind of manner, but treating them in a manner that's not consistent with their condition. You don't want to give someone a care. and I think the other s the other thing that is very important is try to avoid mental health care diagnoses. Please, you are not mental healthcare professionals. Yes, someone can tell you they have anxiety, but treat the symptoms. Okay. Don'treat the anxiety because you're not treating anxiety. You're treating the symptoms of the anxiety. And that's very important because if you're treating a c patient for anxiety, four one nine, whatever it is, and they have anxiety, but it's a situational anxiety, and it's not really truly weren't diagnosed by mental health care professional with anxiety. You know, they're they're anxious because they have this test or that test, whatever the case may be. now they have this anxiety for the rest of their lives and it's in their record. And they want to get life insurance, they want to get health insurance, they health insurance is a is an issue because while the ACA says you can't if you have continuous care, you can't deal with you know prior existing conditions, other plans don't ha don't cover that. If they're not ACA plans, they don't have to take you if you have a history of anxiety because you're a potential risk. They don't want to spend that money. So don't give people mental health care diagnoses.
Angelique and Toby: Insomnia can be con is one for some plans. I triggered somebody's deductible by billing insomnia once. I triggered because I had a separate deductible for mental health. So that one was tricky.
Eoin: That one that is tricky. I can't I can't see that. I mean, insomnia goes with so many other conditions. But that's the thing is okay, so i if you're if they have multiple conditions and you build for insomnia, can you justify taking that insomnia diagnosis off the claim? If it was the primary diagnosis, it's kind of hard to say, No, we're gonna we treated low back pain. But if you treated low back pain as primary insomnia secondary, there's no reason why you can'take insomnia off the claim. Yeah. You know, it because you're you're there to make sure that the patient's getting the care that they need and the care that their body needs and in a in a holistic manner, but ultimately you need to build a in a compliant manner. And one diagnosis is enough. If that diagnosis meets medical necessity, then don'throw every diagnosis in the book at the claim. Yeah. Don't do it. Don't do it. Just pick one.
Angelique and Toby: Sometimes I do too. Okay.
Eoin: Two's okay.
Angelique and Toby: One other so I have a quasi-hypothetical situation. So I have I've heard through the grape vine that sometimes folks have heard themselves that there have been practitioners in the past that have sort of done what you've described. So like someone has come in for wellness care or for something that isn't part of their insurance benefit and they're just like, they've got neck pain. they've got back pain. And then just treated them anyway. And maybe it hasn't gotten figured out, right? At some point, when it does get figured out, if the insurance company doesn't audit, like what actually happens to the provider and what does that look like to the rest of the profession? Like what does that do to the profession?
Eoin: I won't I'll speak to the profession in just one moment and I can only talk from a chiropractic standpoint, but the first thing is documentation. Did the patient document on their intake form that they had these conditions? If they did, then you're halfway there. All right. The next thing is in your documentation, did these conditions cause functional loss and or did was the patient not able to Do things that they needed to do or wanted to do because of it. And did you treat them for 26 times and they're still exactly the same? You know, so the insurance company has to figure out, okay, what is normal, what is a normal number of visits that an acupuncture patient gets? And let'say it's 12, right? The average acupuncture patient gets 12 visits. You treat someone 26 times, they're going to look at you and say, Hey, we want to see your notes to make sure these visits were approved. That's a post-payment option. So they already paid you, they're looking at it to see if whether or not you're okay. The other thing is if they think you're doing things that are not appropriate and you get hit with a prepayment audit, that is they won't pay you until they review your documentation. And that documentation could include the patient history. They might want the patient history. and that And that means you to have one. That's the other thing. You have to have a patient history. You have to have an initial exam. You have to have say, hey, care is needed. Treatment plan really helpful. but so you have a prepayment audit, and that prepayment audit is: was this care medically necessary? Now, if it was, then you're good. Then you'll eventually get paid. All right. If it was and it's good, but they decide not to pay you or they want their money back or they don't and prepayment they don't pay you, then you have to fight and file a complaint with the state as an example. that's a situation that we've seen. Now let's go back to as a profession. I can't speak to acupuncturists specifically because it is a relatively new profession from an insurance building standpoint. I mean, some insurance companies just started covering acupuncture. California, they've been covering it for decades, but I will talk about from a chiropractic standpoint. And in chiropractic standpoint, Medicare covers chiropractic care for speci very specific conditions and for a certain number of visits based on a d a diagnosis. And there's no set number of visits. So the Medicare had a contractor that did an audit and the audit came back that 93% of the care that was provided was wellness care or maintenance care. Now, that's very damning evidence to say that you're not practicing in a way that's consistent. But what it really was a wake-up call saying, Your documentation stinks. And you do need to t keep in mind that patients have to have medical necessity, that you have to meet that medical necessity requirement to be continue to treat them. You can't just continue treatment. You have to let them go. So the a lot of the Medicare contractors did a lot of audits and went back and looked at notes and they asked for hundreds of thousands of dollars back in many cases. I know providers who've who've bought these and lost and bought them and won. But what is d what does it do with the profession? It makes a profession look like you're a bunch of scumbags. I had I don't want to use that term. now. We practice in New York. New York has quite a few what are called mills, you know, personal injury mills in and work comp mills, not so much because work comp is highly regulated in New York, but a personal injury mill is where an attorney sets up a relationship with a provider to establish the treatment of care. And that treatment of care establishes that the person was legitimately injured and the person gets care. eventually there'some sort of lawsuit in the settlement. The question is, was that care because the patient wanted to sho to generate more revenue for that, you know, for the patient? Or was it in fact, care that was medically necessary and the patient needed it? And there's two sides to every coin, as we say. And certainly there are inappropriate things on one end, but there are pretty legitimate injuries on the other side. It doesn'take much to get hurt in a car accident. and I will say that. One of the reasons why I don't practice as a chiropractor is because I had three car accidents ten years. So there's there's legitimate ways. So what does that mean? That means I've lost I've lost my profession. I lost my job. Very tough for me to accept. But was I getting care regularly to see if I could get better? I was. But there's a certain point at which I'm just not gonna get any better. And that's when you see stop care. And that whole idea of terminating care is so foreign those of us who practice in a manner that means that you get the care that your body needs, not that the care that's necessarily medically necessary. And that's that tradition, that treatment tradition of essentially maintenance or wellness care doesn't work in a Western model. Yet we still try and cram it in there. Yeah. And patients still expect it. And I had a conversation earlier today with someone that a particular insurance company Only pays a certain dollar amount for claims and you can balance bill the patient. You're in network, but you can balance bill the patient up to the allowed amount. This only works if you communicate with the patient ahead of time, and the patient understands that they'responsible for X number of dollars, that they're gonna have to pay X number of dollars. That's where the communication comes in with the patient ahead of time, saying, Hey, we have X number of visits from the insurance company. Let's try this short period of treatment. Let's let's try it. Treatment plan says we're gonna try six visits. We'll treat you for six visits. We'll reassess where you are. And that assessment can be something as simple as, hey, I could pick up my grandkids and I couldn't pick them up before. Functional thing, something that's actually so important, particularly if you have little grandkids. or I can walk without falling down. And I will tell you that those of us who have falling problems, that's a win. If you can say I didn't fall down today, that is a win.
Angelique and Toby: Yeah.
Eoin: If you have that treatment plan in place and you have those goals as part of the treatment plan and the treatment plan, that's a whole nother l a whole nother thing about medical necessity. But then you tell the patient, Hey, once you get to the point where you're as good as you're gonna get, we have to stop care because you're now no longer medically necessary. Care is no longer medically necessary for you. But we would love to continue to treat you. We'd love for you to get that and maintain that level that where you're at. But that is maintenance care and your insurance company doesn't pay for it. But here's how we can help you pay for it. Or here's what we can do to help you figure out what works best for you and your body. And have that discussion at the beginning. Saying, listen, your insurance covers this much, the only curve care that is medically necessary, that is that you're going to get better Once you get as good as you're gonna get, we have to stop care. And at that point you can decide if you want to continue with maintenance care. And letting the patient know ahead time. You know, care is not forever. They may have seen another acupuncturist who just treated them once a week for fifty-two weeks in a year. But unless that insurance company is willing to pay for maintenance care, there's you just can't justify that.
Angelique and Toby: Before we close, Toby, do you have any other questions? I see we're getting close to our hour here. Yeah. I have a few, but I'm gonna keep them for next time when Ian visits us. good. We'll get to have him back again if he wants to come out. That would be great.
Eoin: I think that our biggest concern and our biggest issue is that we have a hard time figuring out where we fit in the medical model. And we've placed ourselves in a box that prevents us from billing patients out of pocket for care that is appropriate. For their condition, but not covered by insurance. And because in patients expect that they have these visits and this care, that they are not gonna have to pay or anything or only pay their copay. And that and that's an education component. and that's educating our fellow providers. You know, that's educating new grads coming out of school. that's helping existing providers have been doing things a certain way and understand, hey, that's not really the way to do it. So there's a lot. That goes into this profession of chiropractic and acupuncture, this holistic medicine idea, if you want to use that term, that we need to educate our providers to say, hey, you gotta do it a certain way to show that this care is needed, because we want you to be successful. We want you to help people for the rest of their lives. But we want you to do it a way that's not going to jeopardize everyone else's ability to stay in practice and everyone else's ability to stay in insurance. and I just wanna end with I love to educate the providers that we work with. but at the same time, I hate disappointing providers. And there is a certain level of disappointment that comes with learning that they can't do certain things that they want to do. But it's kind of like the tough love approach to you know practice. Hey, this is what this is all you can do. I would love to be back sometime if you'll have me. But there'so many little things that acupuncturists and chiropractors can do to help establish and medical necessity, help show that the care is needed. And it doesn'take much. It just takes a line or two in their notes and it takes an extra form the patient fills out. And it takes, you know, doing re-exams, even though they don't get paid for them, doing little re-exams and establishing changes. And if we do those things, then we can show that the care we need is medically necessary. And then we can show that we are responsible providers and working within the scope of our practice and the scope of what the insurance company's gonna pay for. And they're not gonna drop acupuncture as benefit. do it the right way, and we'll all be happy.
Angelique and Toby: Thanks so much, Ian, for being here with us.
Eoin: My pleasure.
Angelique and Toby: Thanks for thanks so much for your time, Ian. We'll see you next time.
Eoin: My pleasure. Yep.
Angelique and Toby: Bye. All right. Bye for now, everybody.
Eoin: Bye.
