Acupuncture is an example of the games health insurers play with benefits

Though I can't prove this scientifically because I'm not a controlled experiment, there's good reason for me to believe that I've benefited from my acupuncture treatments for low back pain and the related sciatica from Karen Kaufman.

I talked about this in a June 2024 blog post, accurately titled "I benefited from my sessions at Salem's Innerhealth Acupuncture Clinic."

I'm convinced that Kaufman helped relieve the sciatica pain in my right leg considerably.

Naturally I can't be sure of this, since I'm not a random controlled experiment, just one person who was drawn to try acupuncture after physical therapy didn't do much to relieve the pain, over the counter medications did next to nothing, and I had to wait quite a while to get an epidural steroid injection in my back.

I had two acupuncture treatments prior to getting the epidural injection from Salem Pain and Spine Specialists on May 13. By the time of the injection, the pain in my leg was considerably reduced. I ascribe that to acupuncture, since this was the only thing I'd done differently prior to the injection.

Since, I've continued to get acupuncture treatments about every three weeks. My back and leg pain have stabilized. There's still quite a bit of discomfort, but compared to the excruciating pain I was in before, I can live with the discomfort -- since now I'm not limited in what I can do, whereas before I was.

So when it became clear near the end of 2024 that I should change from my Regence MedAdvantage plan because Regence and Salem Health hadn't been able to agree on a contract extension for 2025, I wanted to be sure that my new MedAdvantage plan covered acupuncture treatments.

I asked about this when I signed up by phone for Providence MedAdvantage in November of last year. The person I talked with didn't go into details, but I was told that yes, the Providence Medicare Choice +Rx (HMO-POS) plan I'd selected did indeed cover acupuncture.

However, when January 2025 came around and my Providence MedAdvantage plan went into effect, I got a bunch of materials from Providence. One was this double-sided 2025 Benefit Highlights sheet.

Under Benefits, you can see that Acupuncture is shown as Not Covered under both In-Network and Out-of-Network. That concerned me, being at odds with what I'd been told by the person at Providence who signed me up for this Medicare Advantage plan.

I phoned Providence on January 8, 2025 to find out what was going on. I was told that actually my Providence MedAdvantage plan did cover acupuncture for up to 12 sessions that have to be completed within 90 days, with 8 additional sessions covered in a calendar year if my condition is improving from acupuncture. I also was told that Karen Kaufman is an In-Network acupuncture provider.

So far this year, Kaufman hasn't been paid by Providence for the acupuncture sessions I've had with her. Recently I got a letter from Providence saying that they denied payment "because the services you received are not covered under your Medicare Advantage plan."

That led me to call Providence and ask what the heck was going on, since I'd been told that acupuncture was covered under my plan. The person I spoke with checked and told me that there was some sort of coding error with the diagnosis code. OK, Kaufman is asking her billing person to look into this. Probably we'll be able to figure out the problem.

What irks me more, though, is how difficult it is for someone to learn via the Providence MedAdvantage web site what the benefits of their plan truly are. As noted above, the 2025 Benefits Highlights sheet I was given by Providence says that acupuncture isn't covered. I only learned that it was through a phone call to Providence.

Providence is playing some disturbing games with the information they're giving, and withholding, from people who either have their Choice Medicare Advantage plan or are inquiring about it. The Providence web page for 2025 plans matching my zip code led me to this page about the Choice + Rx (HMO-POS) plan that I have. 

I clicked on every item in the Benefits section. There's no mention of acupuncture being covered. Or any mention of acupuncture at all.

Clicking around the Providence web site some more, and this wasn't easy to find, I located a PDF file of my Medicare Advantage plan benefits. I searched the file for "acupuncture." Nothing. It isn't mentioned here either. Then I noticed the fine print at the beginning of the file:

When You Join Providence

You are not just part of an insurance policy but part of a community of care, focused on your health and well-being. This Summary of Benefits is provided to help you make the right health care decisions. It is a short guide of what we would cover and what you would pay if you joined our Providence Medicare Choice + Rx (HMO-POS). To be clear, this is not a complete breakdown of benefits, and will not list every servicethat we cover, nor every limitation or exclusion. Plans may offer supplemental benefits in addition to Part C and Part D benefits.

For a complete list of services that we cover, please refer to the Evidence of Coverage (EOC). You can request a printed copy by visiting ProvidenceHealthAssurance.com/EOC or by calling our Customer Service department at one of the numbers listed in the “Get in touch” section below.

So I copied in the URL in the last paragraph, which isn't clickable by the way, and was taken to this page. Under the Evidence of Coverage section, I found my Choice plan, clicked on the Evidence of Coverage link, and was presented with a 257 page document. When I searched it for "acupuncture," I finally found the information about acupuncture coverage on page 59 that I was told about in my January phone call to Providence. 

Obviously Providence made this very difficult to find. I complained about this to the Providence person I talked with this month after they denied payment for the acupuncture treatments I've gotten in 2025, pointing out that neither their Benefit Highlights nor the plan benefits PDF file contained any mention of acupuncture -- only the 257 page Evidence of Coverage file did.

It sure seems like Providence is doing everything possible to make it as difficult as possible for their Choice +Rx clients to obtain acupuncture treatments.

These are part of the basic Medicare benefits, so I assume Medicare Advantage plans have to cover acupuncture. However, I guess those plans are free to play games with their clients by disguising the fact that they're entitled to acupuncture -- unless they phone Providence and ask about this, or are computer savvy enough to wend their way through the Providence web site and find the hard-to-find Evidence of Coverage file.

Comments

[M]

Our insurance companies are also dealing with "coding" issues. I dealt with this earlier this year.
My specialist, who i only visit once ever three years (as that doctor prescribes), had billed me an exhorbitant amount for a 15-minute office visit!
Upon contacting my insurance company, they said they pay according to individual coverage and provider billing codes.
So, I contacted my provider's billing department. First, they explained that if a patient has not been seen for two years, then the patient is considered a "New Patient".
Under this qualification, the specific billing code is for an exorbitant amount, of which our 'excellent insurance coverage' only covers a percent.
The real issue that health insurance companies, medical providers, and we as patients must confront, being catalysts for change, is the fact that the antiquated American Medical Association (AMA) determines the bill coding system.
The AMA is doing more harm to the American people than help. It is not a healthcare system, but rather a sickcare system. Not responsibly seeking the sources of illness, but rather only treating the symptoms. Focused on antiquated methods and partnering with the pharmaceutical industry for no other purpose than monetary greed.