In this article, we give you a behind-the-scenes look at what practitioners in healthcare practices go through to try to work with insurance and why it may not actually be your friend but something that’s hurting your health more than it’s helping it.
Let’s also talk about helping to rejuvenate health and improve quality of life…Not disease treatment, not symptom management, but actually trying to maximize and improve our health to our greatest wellbeing. In order for us to really express the greatest version of ourselves, we need to have great health.
Insurance does not help you do that, unfortunately.
Let’s go through some things today, which can be educational for some of you who may or may not understand how insurance works and what providers go through when trying to use insurance benefits, such as:
- Medical Necessity. It can be very limiting in what services you’re actually able to do…Doctors are always very frustrated by the fact that they’re not actually able to recommend the things that they really want to recommend because of this.
Insurance companies come up with their own medical necessity guidelines. Does medical necessity mean what does the person qualify for this treatment under insurance guidelines? Insurance companies have their own guidelines, and if requirements are met, only then can a person utilize the service they qualify for.
Example: Knee problems- if a patient comes into our office from having knee pain, we would examine them to do an x-ray, and should they be recommended hyaluronic acid injections which have about 5-6 brands, and availability can depend on their insurance coverage guidelines.
What actually ends up happening is the person has to have failed treatments prior to getting to do the thing that she wants them to be able to do, which doesn’t make any sense. Most of the time, the whole reason why somebody is doing hydronic or gel injections in the knees is that they don’t want to do cortisone or anti-inflammatories. Because they know that those things are not good and have more side effects. The gel is more natural, helps lubricate the joint actually improves function.
So what you have to do is fail some type of medical treatment before you can actually get a couple of different types of treatment before you can get the thing that she lacked to give you in the first place. Some other examples would be different types of joint injections, trigger point injections.
We used to be able to do multiple trigger point injections in a short period of time. Which would pretty quickly reduce the spasm or the irritation in the muscle. Now the regulations are, you can only do two and they have to be a week apart. And then you can’t do another one for another six weeks. And that just doesn’t equate well to what is best served by the patient.
- Pre-authorization. This means we do an examination before we can do any treatment. We have to send it to the insurance company so that it can be pre-authorized and they could decide whether they’re going to pay for it or not. The patient has to meet a set of guidelines set up by the insurance company, not by the provider. In order to determine whether they can do that service or not.
Many times when we’re trying to do pre-authorizations again, going back to the hyaluronic acid injections, the insurance companies actually choose which injections the provider can use. Some might cover Synvisc. Some might cover something else. Some others may cover Orthovisc or there’s Supartz, or there’s a list of several different options.
But it’s not the medical providers’ choice it’s the insurance company’s choice and that is absolutely wrong. Same thing with blood work. So vitamin D. We know that patients should have their vitamin D checked and you have to meet a certain set of criteria in order for that to get covered or paid for. And many times it’s not deemed medically necessary as told by an insurance representative, because everybody has low vitamin D, so it’s not necessary to test.
However, the reason we perform a test is to find out how much we need it increased if it’s low, how much vitamin D supplement we would want to do. And then we retest it to find out if it actually works or not.
That’s what happens when we leave those decisions up to the insurance company. They talk to providers, their guidelines are set up that we do the cheapest or the least expensive thing first, maybe not the best. And if that works, then you’re done and we don’t move on from there.
Which is not always providing the best care to the patient. But if you want them to pay for it you have to play by their rules. So that’s pre-authorization. So it has to be reviewed by somebody that’s never seen the patient before just reading the documentation and making a decision on whether they can get said service or not.
- Medical Guidelines. A treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life or therapy that is performed to maintain or prevent deterioration of a chronic condition is deemed not medically necessary.
On the contrary, you would think that if somebody were trying to do something to enhance their quality of life, our promote or prevent deterioration of a chronic condition that would actually save the insurance company money because they would need less treatment in the future, but that’s not covered.
So patients always ask us in our office. Hey, my insurance company says I get 12 visits a year. That is not true. You may get 12 visits a year. But you have to use them in a treatment plan for an acute condition, not for maintenance or wellness. That is a Medicare guideline.
That’s all unfortunate, but when someone else is paying for your bill and their job is to make as much money for their shareholders as they possibly can. To be as profitable as possible. I don’t know if you guys have ever read this. Go and research. Bonuses paid out to health insurance CEOs. Their bonuses are paid out based on money that is the profit for the year. How do you make more profit for the year? You raise, raise rates, and reduce spending. Therefore, reduce coverage.
With this, we urge You- to be very, very careful about letting insurance dictate the type of healthcare we want. Your health is an INVESTMENT, not an expense! ….Make the best decisions for YOUR health as you possibly can.
If you have health concerns or questions, please let us know. We have insurance verification experts here in our practice that can help and get you specific information about how your insurance would be covering services in our practice the steps that we have to go through. Contact us at Advanced Health and Wellness for a free discovery call. We’d love to hear from you soon!
