How the Insurance Model is Set up
The insurance model is based on the standard of care. The standard of care is 15-30 minute office visits and managing chronic disease states. There is no in between or getting to know you in conventional medicine. There is no doubt that conventional medicine, based on the standard of care, is failing to improve the health of Americans.
In contrast, functional medicine is root cause medicine. We function outside of the standard of care, still using research driven practices. Did you know that is takes an average of 18 years for a new, proven intervention to make it to conventional medicine before the guidelines change? That is a ¼ of ones life! Being a part of the functional medicine movement is the best medicine, we are based on helping patients improve lifestyles, develop therapeutic relationships, optimize wellness and get to the root cause of disease to reverse chronic disease states!
How Functional Medicine Works Within the Insurance Model
It’s critical to understand the how and why you can use your insurance to receive functional medicine care. Dr. Paulson writes this having worn the hat of working for the insurance company reviewing claims for denials, working in the hospital setting as a RN, working in conventional primary care under the model of reimbursement based on # of patients seen and # of office procedures performed and now for the past 11 years, running an insurance based billing practice. She has gone through a full on insurance audit for “high dollar claims” and was told by an insurance company CEO that functional medicine should not be billed to insurance.
Fortunately, the newest insurance billing guidelines do allow providers to bill based on time and complexity of the patient’s medical history so we can have longer visits than 30 minutes. However, our insurance claims are often flagged as “high dollar” and we get requests to send in full files of medical records to justify our time and billing codes. By now you are understanding that a provider and clinic must really know how to maneuver the “art of insurance billing”.
Believe me it has been tempting to transition to a cash pay model, but every time I think of doing that I think of all the middle-class patients I have had the opportunity to guide to a path of wellness and I know damn well they would not have been able to afford cash pay rates. I also believe that all medicine should be functional medicine and I want the insurance companies to pay for this care. So we go on. But it’s important you understand the facts and how your insurance will work
Here are the Facts and the “Need to Knows”
- We have a dedicated billing manager, Steve Paulson. Dr. Paulson trained him on coding and billing in 2015 and he has been in this role since. Please direct all billing questions to Steve via a secure portal message or billing@aspire-wellness.net
- You are responsible to know your insurance benefits.
- We have primary care providers in our clinic, specialists (mental health), and nutrition so we are looking at all of those benefits under the patients insurance plan
- Insurance benefits are always subject to medical necessity.
- Your insurance is a contract between you and the insurance company and possibly your employer if employer sponsored. This means if your insurance denies a charge, the balance due is your responsibility. We bill your insurance as a courtesy and service to you.
- We will always verify your benefits via the insurance verification tool and you should also know your benefits.
- Service “office” visits are fairly easy for us to get covered as we use the diagnostic codes that are applicable to your medical history, lab findings, diagnosis.
- We do not verify your lab benefits. We recommend cash paying for your labs.
- Many of your labs will likely be denied as not medically necessary. For this reason we have established “cash pay” accounts where we bill your labs through this discounted account with a $40 admin fee for our time to create and bill this lab order through this account.
- Your insurance company will likely find Vitamin D not medically necessary unless you have Celiac disease, short bowel syndrome, osteoporosis, or GI malabsorption. The lab will charge you $222 for 1 Vitamin D test when we can bill that test for $35! Same applies to homocysteine, which is a great serum marker to tell your provider if you are methylating!
- Once we tell the lab to bill your labs to insurance, the cost goes up 4-6X. I.e. a cash pay $250 lab panel will get billed to insurance as $1000.
- Your insurance company is not going to cover most things that make you healthy. I call these things health investments: functional lab tests, vitamins, gym membership, wearable health tracking devices. The worst mistake you can make is to let your insurance company dictate your medical decisions. I say this for getting labs, selecting health screening tests, investing in vitamins and any health wellness tool or membership.
- We are happy to discover that many insurance companies will pay for a few nutrition visits under preventative wellness coding! Some allow more visits than others. We recommend checking with your insurance for this benefit and take advantage of meeting with our functional medicine Registered Dietician
