Working Wellness Around the “System,” part 5

posted in: CYJ Blog, Lifeskills, Wellness

Is It Covered by Insurance?

For much of my life, I was in a doctor’s office for one reason or another. As a child, I was very sickly. Had a tonsillectomy and almost died from blood poisoning from the infection that flooded my system when the surgeon cut out my tonsils. That was just the beginning of my journey going from doctor to doctor trying to figure out why I felt so exhausted, anemic, jaundiced, digestive pain, along with other degenerative ailments.

It wasn’t until I was about 34 years old and collapsed after birthing my second daughter I decided, out of desperation, to check out other options and flew to a California metabolic disorder clinic. Like no other doctor or hospital stay, they discovered severe malabsorption of foods that created a spiral of allergic and degenerative disorders through the years. I was eating but starving to death. The year 1981 was the beginning of my 20+ year road back to wellness navigating between conventional and complementary/alternative medicine (CAM). What a breakthrough when I finally located a local integrative MD who was willing to truly listen to this patient who learned a lot along the way, that’s for sure! Can’t help but believe God was nudging me on all the way!

Today, as a grateful and bright-eyed 72 years old, I probably would have died years ago without the help of so many healthcare providers of all persuasions, conventional and integrative. One of the big questions I always asked was “Is this covered by insurance?”

I can remember so many times when the prescribed therapy was not covered by insurance. Some doctors did help complete medical necessity letters when I was submitting a claim for reimbursement. Sometimes, it worked, other times, no. When it did work, much of the reason was my persistence. I never gave up trying. Yet, over the years, I saved a lot of money and hopefully helped insurance companies change the way they did business, at least a little. Then there were savvy doctors who knew how to use diagnostic codes to get coverage. God bless them!!

According to the National Center for Complementary and Integrative Health (NCCIH), “People seem to be willing to pay “out-of-pocket” (not through insurance) for certain complementary health approaches. In fact, out-of-pocket spending on these approaches for Americans age 4 and older amounts to an estimated $30.2 billion per year, according to the 2012 NHIS.” This total includes out-of-pocket for CAM provider visits, various “natural” products, and an assortment of CAM self-help materials. CAM out-of-pocket spending in 2012 was 9.2 percent of total health care expenses ($328.8 billion) and 1.1 percent of total health care spending ($2.82 trillion).

Around 10% of our total healthcare expenditures doesn’t seem a lot but does add up, particularly as you use more integrative and CAM services. So, before you begin, check your insurance company for coverage limits. There are more companies every day including some CAM coverage, such as acupuncture, massage, chiropractic care, and mind/body treatments. The NCCIH suggests you ask your insurance company the following:

  • Is this complementary or integrative approach covered for my health condition?
  • Does it need to be preauthorized or preapproved?
  • Ordered by a prescription?
  • Do I need a referral?
  • Does coverage require seeing a practitioner in the network?
  • Do I have coverage if I go out-of-network?
  • Are there any limits and requirements—for example, on the number of visits or the amount you will pay?
  • How much do I have to pay out-of-pocket?

Include in your questions any additional costs covered, such as lab tests, nutritional supplements, equipment, or supplies. Find out what local providers are part of your policy network.

When searching for a new health insurance plan, the same questions apply. Find out if you need a special “rider” or supplement to the standard plan, and what specific integrative/CAM therapies are included? Ask if insurers also have a discount program with lower rates when plan members pay out-of-pocket services and products. See if your employer might offer a flexible spending account to set aside pretax dollars for uncovered health-related expenses. Look over all your options. Also, feel free to cruise through the US Department of Labor for general information on health plans and benefits.

If your insurer doesn’t necessarily cover integrative or CAM, how about giving it a try convincing them your desired integrative/CAM care will be more cost-effective than standard medical treatments, such as surgery and medication. You will need to do some homework with credible sources such as PubMed articles or sources your provider recommends to have a chance of winning over the insurer.

Once you have done your insurance homework, the next article (part 6) for this series will cover how integrative/CAM practitioners handle insurance or not.