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Aetna’s Sea Change: Emerging Trends in Acupuncture Coverage (Guest Post by Andrea)

This is a public service announcement about AetnaIf there’s one thing we can count on in the American insurance industry, it’s change.

Billing techniques, filing requirements, and policy details can (and often do) change dramatically from year to year. As Acubiller’s benefit team researches policy information for our growing client base, we look for emerging trends in coverage.

Aetna’s corporate coverage guidelines for acupuncture are laid out in Clinical Policy Bulletin #0135. For Aetna patients with an individual plan, CPB #0135 is an invaluable resource. It provides a list of approved procedure (CPT) and diagnosis codes that can be used when billing acupuncture for an individual plan.

For the last several years, employer group plans have usually followed the guidelines listed in CPB #0135.

But we recently identified an emerging trend that affects many new Aetna patients.

In 2018, we’ve seen a notable increase in the number of employer group plans that allow acupuncture, but do not follow CPB #0135. Many employer groups are writing their own coverage policies for acupuncture.

Some employer group plans are more restrictive than Aetna’s corporate standard, while others are more inclusive, allowing a wider range of diagnoses and procedures.

What This Means For Providers

When employer groups write their own coverage policies, coverage and diagnosis restrictions can differ greatly from one employer to the next. What does that mean for healthcare providers?

  • For Acubiller clients. When you request benefits for an Aetna patient, include any Dx codes you plan to bill. It takes some of the guesswork out of billing, and may support reprocessing or appeal.
  • Proceed with caution. Check patient benefits before treatment. Observe all policy requirements. Heed all policy restrictions.
  • Get used to voluntary predetermination. Voluntary predetermination is the best way to check coverage for specific CPT and Dx codes. Response time is typically 7-14 days.
    • Submit to Aetna via fax at: 859-455-8650 to Attn: Predetermination Request. Include:
      • Chart notes (if relevant)
      • A list of CPT/Dx codes you’d like to bill
      • Place of Service (“Office”)
      • facility address
      • patient info (name, ID, and DOB)
      • provider info
      • a return fax number
  • Bill and follow up promptly. File claims immediately to avoid denials for timely filing. If your EOBs show unexpected results, contact the carrier right away.

Aetna: Old and New

It’s not just Aetna’s employer plans that have been revamped. We’re also seeing an increase in the number of Aetna policies that adhere the Affordable Care Act’s non-discrimination clause.

The scope of an acupuncturist’s license covers three separate benefit categories:

  • Acupuncture
  • E/M (evaluation and management, or office visits), and
  • PMR (physical medicine & rehab, listed under physical therapy)

The Old: Before the ACA’s non-discrimination clause was in place, all services by a licensed acupuncturists were “lumped together” and paid under a single benefit category.

As a result, if acupuncture (needle therapy) was not covered, insurance carriers wouldn’t pay you for exams or modalities, either.

For the last several years, Aetna has operated that way: if a policy excluded acupuncture, they wouldn’t pay for any service by an LAc.

The New: Fortunately, many newer Aetna policies will allow exams and modalities even if acupuncture is disallowed. At least on newer policies you could be paid for the other services you performed. (It beats nothing!)

Moving Forward

When an insurance carrier like Aetna significantly changes their coverage policies or filing requirements, it affects you as well as your patients.

When a patient is in pain, jumping through the carrier’s hoops is likely the last thing on their minds. But if they want to avoid out-of-pocket expenses, rushing into treatment may not be a wise choice.

In many cases, you are the patient’s last line of defense against unwanted out-of-pocket charges. So encourage your insurance patients to plan their treatment with care – it’s a great way to build rapport and trust with your clientele.