In today’s fragmented healthcare environment, acupuncturists treating chronic pain patients with PPO insurance plans — particularly those with back pain and chronic postsurgical pain — are often faced with an ethical and clinical dilemma. While acupuncture provides measurable relief and functional improvement for these patients, it often reveals a glaring gap in their broader healthcare management.
These patients typically arrive with a trail of pain management interventions: epidural steroid injections, spinal cord stimulators, opioid or non-opioid drug regimens, occasional physical therapy sessions, and surgical consults. Despite this intensive specialization, many lack a functioning relationship with a primary care provider (PCP).
It is not uncommon for these individuals to have gone a decade or more without basic screenings — no mammograms, no Pap smears, no colonoscopies, and no routine bloodwork. This clinical reality presents multiple layers of risk.
1. Patients Are Falling Through the Cracks
PPOs allow patients to access specialty care without referrals, which makes it easier to go directly to pain management or surgical consults without ever establishing care with a PCP. The result is a hyperspecialized, non-integrative model of care that often fails to assess the whole person. Conditions may go undetected in these patients until it’s too late.
As acupuncturists, we may be the only healthcare providers consistently seeing the patient in a hands-on, relational capacity. We palpate their pulses and talk about digestion, sleep and emotional well-being — areas long neglected by their procedural care. We may be the first to notice concerning symptoms or ask about overdue screenings. And yet, we are often not recognized — or reimbursed — for the gatekeeping role we’re forced to play.
2. Clinical Authority Collides With Patient Perception and Cost Sensitivity
In states like California, licensed acupuncturists are legally permitted to order diagnostic tests and bill for the cognitive services involved. However, when these tests are ordered, patients often refuse to pay for the additional service. The alternative — referring the patient to a primary care provider — is frequently disregarded, as many patients assume this care is unnecessary, particularly when none of their other “real doctors” has recommended it.
Acupuncturists may opt to provide these additional services without charging, resulting in hundreds of hours of uncompensated work.
3. The Liability Triangle: Acupuncturist, Patient and System
Acupuncturists navigate a delicate balance between compassionate care and clinical liability. When signs such as worsening fatigue, unexplained weight loss or irregular bleeding arise, we have an ethical responsibility to refer the patient for further evaluation. However, when patients repeatedly refuse to follow through with referrals, it complicates documentation and increases potential legal risk. In such cases, the most appropriate course of action may be to discontinue care due to noncompliance.
Moreover, if we don’t ask about these symptoms, or fail to refer or test appropriately, we risk missing serious diagnoses and being held accountable for negligence — even though the system itself left these patients without basic care.
Recommendations for Acupuncturists
- Document Everything: Every conversation about missing primary care, referrals, or declined screenings should be clearly documented in the patient’s chart.
- Develop Referral Networks: Create working relationships with PCPs, labs and low-cost screening centers that accept self-pay or work with PPO patients.
- Use Screening Questionnaires: Ask chronic pain patients if they have a primary care provider prior to accepting their case. Incorporate comprehensive screening into your intake form: When was their last physical? Last mammogram? Last colonoscopy?
- Be Transparent About Billing: Make it clear that the out-of-pockets fees for ordering and interpreting tests are not included in fees for acupuncture.
As the healthcare system becomes increasingly fragmented by subspecialization and insurance-driven silos, acupuncturists are often thrust into the role of informal care coordinators — particularly for chronic pain patients navigating the complexities of PPO coverage. Although this role is rarely acknowledged or reimbursed, it is essential to include appropriate fees for the time and expertise required. This service not only supports the patient’s overall well-being, but also helps safeguard our profession from ethical and legal liability.
