In-Network Acupuncture Benefits Via Health Insurance

Health insurance is an intentionally complicated system here in the United States. As we’ve navigated and worked with insurance plans for the past 7+ years, below is a couple of topics in regards to Insurance Terminology, Medical Policies regarding Acupuncture, Coverage, and examples of Coverage. At the end of the day, your insurance benefits are your responsibility as a patient. Your employer, human resources department, benefit department, or your insurance broker are the ones that you should contact if you have questions about your coverage.

All costs for services rendered at Box Acupuncture will go to the patient, in the event that coverage lapses, changes, or if the health insurance benefit for whatever reason is not covered.

At the end of the day, we are in-network with many health insurance companies and plans, not because of the money, but because we want our services to be accessible for patients so that they can experience the benefits of Acupuncture and Traditional Chinese Medicine.

In-Network vs. Out-of-Network Providers: An In-Depth Guide

1. In-Network Provider

Definition:
An in-network provider has a signed contract with an insurance company to provide services at negotiated rates. The insurance company lists this provider in its network directory.

Pros:

  • Lower out-of-pocket costs for patients.

  • Typically, predictable reimbursement rates (plans change year to year)

  • Easier claim processing.

  • Less patient confusion over costs.

Cons:

  • Lower reimbursement rates due to negotiated fees.

  • Greater administrative work (pre-authorizations, strict billing guidelines).

  • Insurance may delay or deny payments.

  • Subject to insurance company audits and medical necessity reviews.

2. Out-of-Network Provider

Definition:
An out-of-network provider does not have a contract with the insurance company. The patient may still use their insurance (if they have out-of-network benefits), but costs are typically higher, and reimbursement is lower.

Pros:

  • Fewer diagnostic restrictions from insurance companies.

  • Less insurance health plan oversight on treatment.

Cons:

  • Patients face higher out-of-pocket costs.

  • An insurance company may pay nothing or only a small percentage.

  • Unknown reimbursement rates and costs

When Should a Patient See an In-Network vs. Out-of-Network Provider?

In-Network Provider: When to Choose

✅ If cost savings is a priority

  • In-network visits generally cost less because insurance companies have pre-negotiated rates.

  • Copays are lower, and out-of-pocket maximums are easier to reach.

✅ If using insurance benefits is important

  • Patients who want to maximize the value of their insurance plan should stay in-network.

✅ If prior authorization or visit limits are in place

  • Many insurance plans only approve acupuncture or dry needling visits if they are with an in-network provider.

✅ If seeking routine or ongoing care

  • For maintenance visits, wellness care, or chronic condition management, in-network care helps control costs long-term.

Out-of-Network Provider: When to Choose

✅ If you want to see a specific provider known for expertise or specialty care

  • For top-tier sports medicine acupuncturists, specialists in groin/pelvic rehab, or advanced red light therapy, patients may choose out-of-network care because the provider offers expertise that’s hard to find.

✅ If your plan has strong out-of-network benefits

  • Some PPO plans cover a significant portion of out-of-network costs, giving patients more choice.

✅ If the in-network options don’t meet your needs

  • For example, if no in-network provider offers the specific type of care you want (sports recovery, post-surgical rehab, elite performance acupuncture, 7-wavelength red light therapy), out-of-network is often worth the investment.

✅ If results are more important than cost

  • Professional athletes, executives, and VIP clients often prioritize speed of recovery and level of service over insurance savings.

✅ If you're using FSA/HSA funds

  • Many out-of-network services can still be paid with tax-advantaged HSA/FSA funds.

Key Health Insurance Definitions

Copay

  • Fixed amount the patient pays at the time of service (e.g., $20 per visit).

  • Does not count toward the deductible, but often counts toward the out-of-pocket max.

  • In-Network Co-pays range from $5-$50, depending on the plan.

Coinsurance

  • Patient pays a percentage of the allowed amount after the deductible is met (e.g., 20% of the visit cost).

  • In-Network Co-Insurance costs can be anywhere from 5%-30% of the allowed amount.

  • Example: Let’s say your deductible is $1000; this is how much you must pay out of pocket before insurance begins sharing the cost of your treatment. Let’s say the allowed amount for a treatment is $100; that means when billing your insurance, $100 will be applied to the $1000 deductible. After 10 treatments (10 x $100 = $1000), insurance will begin covering part of the cost of your treatment. If your co-insurance is 10%, your insurance plan will cover 90%; so you will be required to pay $10 after the first 10 visits because you’ve met your deductible.

Deductible

  • The total dollar amount a patient must pay out-of-pocket before insurance starts covering services.

  • Example: $1,500 yearly deductible—patient pays the first $1,500 in services.

Out-of-Pocket Maximum (OOP Max)

  • The maximum amount a patient will pay in a year for covered services.

  • After this is reached, insurance covers 100% of covered services for the rest of the year.

  • Typically, the OOP Max accumulates from the deductible, co-pays, and co-insurance costs.

  • Example: if your out-of-pocket max is $3000, and you’ve already met $1500 since your deductible was $1500. Then every $10 that is paid will go towards the out-of-pocket max. Once your out-of-pocket is met, then you’ll pay 0% as your insurance will cover 100%. In California, because Acupuncture treatments go towards medical insurance, anytime you go to the doctor for daily check-ups, lab work, etc, it will all go towards a deductible and out-of-pocket amount.

Benefit Limitations

  • Limits on what insurance will cover (e.g., 20 acupuncture visits per year, no coverage for cosmetic acupuncture).

  • May also include non-covered services or dollar caps.

CPT Codes (Current Procedural Terminology)

  • Standard codes used to bill insurance for procedures performed.

  • Example:

    • 97810 — Acupuncture, initial 15 minutes

    • 97811 — Acupuncture, additional 15 minutes

ICD-10 Codes (Diagnosis Codes)

  • Codes used to describe the patient’s diagnosis or condition.

  • Must support "medical necessity."

  • Example:

    • M54.59 — Other Low back pain

    • R51 — Headache

Premiums

  • The amount paid monthly for insurance coverage (by employer, employee, or both).

Prior Authorization

  • Insurance requires review and approval before treatment is provided.

  • Without prior authorization, insurance may deny coverage even if the service is typically covered.

Claims

  • The request for payment sent from the provider (or the patient) to the insurance company after services are rendered.

  • Electronic or paper format.

  • Includes CPT, ICD-10, provider info, and patient info.

Explanation of Benefits (EOB)

  • A statement sent by insurance explaining how a claim was processed:

    • What was billed.

    • What was covered.

    • What patient owes.

    • Why any services were denied or adjusted.

Exclusions/Limitations

  • Specific conditions, services, or situations insurance will not cover.

  • Example: cosmetic services, experimental treatments.

Third Party Payors

  • Any entity (other than the patient) that pays for health services.

  • Examples:

    • Private insurance (Aetna, Cigna)

    • Workers’ compensation

    • Auto insurance

    • Medicare/Medicaid

  • Third Party Payor Example: American Specialty Health Networks (ASH), which is not an actual health insurance company, but processes on behalf of Blue Shield of California, Kaiser, Anthem Blue Cross, and more. Then, they submit the bill directly to the health plan, and the process begins. How this looks: say we submit a $200 bill to ASH, ASH approves the treatment and submits the bill to Blue Shield, Blue Shield pays say $175 of the $200 to ASH, ASH then pockets $120 of the $175 payout, and then pays us providers the remaining $55 of the $175 bill.

Medical Necessity Review

  • The process by which insurance determines if a service is needed for diagnosis/treatment of a medical condition.

  • Services must be:

    • Appropriate for the condition.

    • Supported by evidence or clinical guidelines.

    • Not more costly than alternative options.

Understanding FSA, HSA, and Superbills for Out-of-Network Coverage

What is an FSA? (Flexible Spending Account)

  • Employer-sponsored benefit account.

  • Employees can contribute pre-tax dollars to pay for eligible medical expenses.

  • Funds must be used by year-end (use it or lose it), though some plans offer a short grace period.

  • Can typically be used for:

    • Copays, deductibles

    • Out-of-network services

    • Acupuncture, dry needling, cupping therapy

    • Some red light therapy (if medically indicated)

    • Over-the-counter items with Rx

  • FSA is owned by the employer, not portable if you leave your job.

What is an HSA? (Health Savings Account)

  • Only available with High Deductible Health Plans (HDHP).

  • Employee contributes pre-tax dollars to pay for eligible medical expenses.

  • No expiration — funds roll over year to year and grow tax-free (can function like a retirement account).

  • More flexibility for out-of-network services.

  • HSA is owned by the employee, portable across employers.

What is a Superbill?

  • A detailed receipt the clinic provided to the patient after an out-of-network visit.

  • Patient submits the superbill to their insurance for possible reimbursement.

  • Contains:

    • Clinic and provider info (NPI, Tax ID)

    • Patient info

    • Date of service

    • CPT codes (procedures performed)

    • ICD-10 codes (diagnosis)

    • Fees paid

  • Does not guarantee reimbursement — depends on patient’s out-of-network benefits.

  • Some insurance plans will count reimbursed amounts toward the patient’s deductible or out-of-pocket max.

How Box Acupuncture Can Help

Our front desk team can provide you with an itemized superbill for any out-of-network visit or cash service (such as red light therapy or cosmetic acupuncture), so you can easily submit it to your insurance or FSA/HSA plan. Many of our patients also use their HSA for acupuncture, cupping, dry needling, or red light therapy — and we’re happy to help you maximize those benefits.