No Such Thing as a Free Lunch, Part Two
insurance billing + WCA = #$@&%*!!!
The introduction to this topic is here and Part One is here. I asked an insurance consultant, “Can you help me understand what about WCA’s operations would have to change in order for us to bill insurance?”
Before getting into their answer, I want to reiterate that this is a post about trade-offs. I’m not saying no acupuncturist should bill insurance ever or that insurance is bad; I’m explaining why WCA — a small business with some unique characteristics — doesn’t bill insurance. The trade-offs aren’t worth it to us, which doesn’t mean they’re not worth it to other acupuncturists.
I totally understand why patients want to use their insurance if it covers acupuncture. They’ve had to put time and energy (and possibly money as well) into getting and keeping those insurance benefits. Of course they hope their acupuncturist takes their insurance! My goal in unpacking all this isn’t to build a case against insurance itself but to support transparency about WCA’s finances and operations — and also, to help our students understand trade-offs in small business.
Okay, here’s what our (long-suffering) insurance consultant said:
In my opinion, in order for you to bill insurance, WCA’s entire structure — all its systems — would have to change.
Let’s start with the way you do your intakes into the clinics. I’ve observed your operations and it looks like people can just walk into WCA and get acupuncture whenever they feel like they want it or need it. Um, no. I understand that’s sort of your brand, but it won’t fly.
The process at the front desk would have to be much more time- and labor- intensive. For new patients, you would need an admin person asking "what insurance do you have?" and getting that information, then following up/checking benefits, calling the patient back to get the CORRECT information, etc. (Remember how I said that everyone is confused by insurance?) For returning patients, no more quick check-ins and then sailing on back to the treatment room. There'd be a line to check in or out of the front desk; your patients would have to get used to waiting a lot more than they do currently.
Every visit would require questions about their insurance -- is everything the same? what’s changed? You’d need to double check all their information before the day of the appointment. So that means no more same-day appointments and no more walk-ins; there wouldn’t be time to check on people’s insurance benefits.
In my estimation, you would need to add at LEAST 2-3 new admin/billing jobs, full time, for the sheer volume of patients WCA sees, and you would also need to factor in extra administrative time to manage those people. No more volunteers at the front desk; interacting with insurance billing isn’t a volunteer job.
Speaking of staff time, WCA acupuncturists would have to spend much more of it on charting. No more simple SOAP notes. They’d have to ask many more questions of the patients; they’d need to remember to chart to “above line diagnoses” and remember to have patients fill out Start Tools and trigger the admin positions to submit Prior Authorizations. Based on what you’ve told me about how you treat a lot of people for un-diagnosable problems on the one hand, simple stress on the other, and then everything in between — you know a lot of those conditions aren’t included in the list of above line diagnoses, right? So the acupuncturists would have to get used to fudging what’s going on with patients in order to make it match an above line diagnosis — or they’d have to highly encourage all your patients to complain about back pain!
If insurance denies a claim, you have to pass that cost off to the patient or eat it. I understand that you don’t want patients to get hit with surprise bills — in fact you don’t currently do any billing at all, do you? okay, wow — so you would probably be taking losses left and right. Remember you’ll have a lot more staff time to pay for, between the new admin/billing people and the acupuncturists having to spend more time charting. You’ve probably never sent a patient to collections? You don’t even know what I’m talking about, do you. Oh boy.
The upshot is that all WCA staff would need to be thinking about insurance at least 75% of the time. It would change the way you talk to patients, schedule patients, check them into the clinic, and take payments. It would change how you think and talk about treatment plans. And it would create a whole new layer of administrative infrastructure for you to take care of.
Insurance would become the new law for WCA’s staff, patients and systems, and you’d have to be willing to obey it. No offense, but obedience doesn’t seem like your strong suit. I’m sure you have other good qualities. But you’d have to change your attitude.
This was the point at which I thanked our insurance consultant and ended the conversation.
When WCA first came into being, almost nobody in our target demographic had insurance that covered acupuncture. WCA’s business and its systems grew organically over time (with the goal of being as low-barrier as possible) and now it’s clear that those systems don’t match what we would need in order to bill insurance. It’s kind of like how organisms occupy ecological niches; they evolve in relationship to the resources available to them. A cactus won’t thrive in a wetland and cattails don’t grow in the desert.
I know some people wonder why we haven’t created ANOTHER set of systems so that we could bill insurance for the people who have it — and that’s why we’re having this conversation about free lunches, or the lack thereof. Systems in a small business aren’t free. They demand time, energy, resources, maintenance, and headspace. In a small business, systems have to earn their keep.
The systems we’d need to bill insurance would have to bring in a lot of revenue just to pay for themselves -- but I’m not sure they could bring in enough to solve the problems they’d create for the rest of WCA’s business. On a certain level, a small business IS its systems. And the more people who are involved in the business, the more important that its systems are solid, consistent, and user-friendly. A low-cost, high-volume business like WCA lives or dies by its systems. Trying to support two radically different sets of systems, including having different rules for different patients depending on whether or not they have insurance, is way more than we can handle. At the very least, trying to bill insurance would change WCA beyond recognition.
The main reason for WCA to bill insurance would be to create more access to acupuncture. There are other ways to create access, though: like building partnerships and working on a 5NP law and educating future community acupuncturists and a variety of other financial maneuvers that I promise I’ll get into in future posts. And as unconventional as those efforts are (and even though they’re not free either) they make more sense for WCA than insurance billing does.