Q: I have a patient who has a limitation of acupuncture services for 20 visits per year but has 45 visits for physical therapy. Is it possible to access and get paid for doing "physical therapy," which for my state is under my scope of practice as an acupuncturist, when the acupuncture benefit is exhausted?
A: It has become increasingly common for insurance carriers to place a limit on services, whether it is the number of visits or a money cap. These allowances may vary from one type of a provider to another and be based on specialty or license. This practice should change once the Harkin amendment on equality is enacted in 2014 under the new health care reform regulations, wherein a practitioner working within their scope cannot be discriminated against.
A common example of limits of care is as you stated. The acupuncture limits of the policy are for 20 visits but there are 45 visits of physical therapy. In the past, it was common that a plan of this type would continue to pay the acupuncture provider for physical medicine and rehabilitation services, such as massage and heat, when the acupuncture benefit was exhausted. Although acupuncture needling was no longer payable, the physical medicine and rehabilitation services would be paid separately. Acupuncture, though provided, would be the responsibility of the patient since there was no further insurance benefit for the specific acupuncture services.
However, I have noted some recent changes where carriers are not allowing a continuance of payment in this fashion. In these instances, the carrier is limiting not the type of service but the specific provider of services. They will deem any service performed by the acupuncturist as acupuncture and any services done by a physical therapist as physical therapy. In fact, that is a correct determination. Based on that, the allowances of services are distinct and separate based on the provider of services and not the type of service.
A prime example is the California workers' compensation system that allows 24 visits to a chiropractor, 24 visits to a physical therapist and 24 to an occupational therapist. However, there are no limits to acupuncture or services by a medical doctor. Therefore because an acupuncturist or medical doctor may indeed do some physical-medicine services, it does not allow providers with limits to access benefits under acupuncture or medicine, which have no limits. It is a limit based on the provider and not the service. Each provider has their own distinctive allowance and may not use another provider's limits after their visit limit is exhausted, regardless of the services provided. This clearly is a limit not of a service but by who delivered the service.
Therefore, we cannot assume that a policy with greater benefits for physical therapy would cross over and allow continued acupuncture care for physical medicine services. In fairness, I am sure that as a licensed acupuncturist, you wouldn't want a physical therapist who has exhausted their benefits to continue using them under the policy or limits for acupuncture.
However, it may be possible that you can continue to be paid for physical medicine and rehabilitation services after acupuncture limits are exhausted. Do not assume such and do a specific verification with the insurance about the allowances, whether by service or provider. Specifically inquire about the limits to acupuncture. Is it based only on needling services and that continued utilization of physical medicine and rehabilitation services will be paid under the higher limits for physical therapy.
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