Could it be that they want higher expenses so the states will approve higher premiums so they can make more money on the financial float and their investments? We know they’d rather pay $50,000 for a heart bypass operation or $10,000 for a heart angioplasty operation than $150 for CAM methods to prevent problems. It looks like these are really financial companies, not companies that care about the health of their customers. How else can you explain their reluctance to save money and lives, and improve the quality of life for their customers?
Have you heard of the term “denial management” yet? It’s one of the hot buzzwords in the healthcare debate going on today. Insurance companies make it a matter of policy to “deny, deny, deny” claims submitted by doctors and hospitals for any minor infraction. But the fact is, it’s nearly impossible not to have a problem with every claim because doctors start out having to select the proper code out of 7,000 basic 5-digit codes devised by the American Medical Association in 1966. In addition, each insurance company has its own constantly changing menu of codes and instructions, like adding “-u5” to an established code to signify the latest update. It’s a moving maze of delaying tactics that the insurance companies claim are designed to improve efficiencies and prevent fraudulent billing. In reality, this paperwork war is estimated to cost around $20 billion per year, about half from each side, in unnecessary administrative expenses, according to a 2004 report by the Center for Information Technology Leadership.
Companies that are self-insured are beginning to realize the fundamental errors of our current system and are experiencing a paradigm shift in their attitudes. They’re embracing wellness programs and health screenings because spending a little money up front saves big expenses later. In a 2006 Wall Street Journal article entitled “The Road to Wellness Is Starting at the Office,” the paper reported on a recent survey by Hewitt Associates that found that 42% of companies offered some type of health-risk assessment in 2005, up from 29% in 2001. Some companies are even setting up on-site clinics.
Be aware that most insurance companies don’t pay for complimentary or alternative therapies because they are classified as experimental or unproven. This is one of the key factors restricting the growth of CAM therapies, and it’s a chicken-and-egg problem. Because most of these therapies cannot be patented like a drug, there is limited profit potential, meaning there are no companies interested in investing millions of dollars for FDA testing. The National Center for Complementary and Alternative Medicine, a division of the National Institutes of Health, is involved with testing and research of these therapies, but their budget is small compared to that of America’s drug industry. Since the NCCAM has only been in existence since 1999, they’re still researching the oldest and most accepted therapies. Their research with the Mayo Clinic on the effectiveness of acupuncture for fibromyalgia was only completed in 2005. At this rate, it will be decades before many of the therapies listed here are evaluated properly.
There are some insurance companies beginning to pay for CAM treatments, usually for acupuncture, massage, chiropractic, biofeedback, and naturopathy therapies. Deductibles for these treatments, however, may be higher than for regular medical care. A few insurance companies offer a special policy rider for CAM coverage, so this may also be an option for you. Your insurance company may also have negotiated discounts with CAM therapy providers for a lower cost. It’s best to discuss your coverage with your insurance carrier before beginning any new treatment.
Some of the questions you may want to ask are:
- Do CAM treatments need to be pre-authorized or pre-approved?
- In order for coverage, do CAM treatments have to be authorized by prescription from a medical doctor?
- Do I need a referral for CAM from my primary care provider?
- Do I have to see only practitioners in your network to be covered?
- What coverage will I have if I use a practitioner out of network?
- Are there limits or restrictions on the number of visits or amount that you’ll pay?
- What will my out-of-pocket expenses for CAM treatment be?
You may also want to contact your state’s insurance department about coverage since there are many differences in state laws and policies. They may be able to help you find companies that offer better CAM coverage and be able to tell you what their ratings are for performance.
On the other side of the issue, there are also questions you should ask any potential CAM provider, such as:
- What does the first appointment cost?
- What do follow-up appointments cost?
- How many appointments are normally required?
- Are there additional costs involved, such as for lab tests, equipment, or supplements?
- Do you take insurance?
- What has your experience been dealing with insurance companies?
- Do I file the insurance claim forms, or will you take care of that?
If you are denied coverage for CAM treatment, there are things that you can do. First of all, know your plan and exactly what it does, and does not, cover. You may also want to check and see if there is simply a clerical error in the coding. Compare the codes submitted on your practitioner’s bill with the codes noted in the document from your insurance company. If you feel that your insurance company has made a mistake with your claim, you can request a review because they all have a process for appealing denial of coverage. You can even ask your practitioner to support your efforts, for example by preparing a letter to your insurance company. You can even file a complaint with your state’s insurance agency regarding the problem.
There are new options to help with CAM expenses like an FSA (Flexible Spending Arrangement) account or an HAS (Health Savings Account). Some employers offer an FSA to help you put aside pretax dollars each pay period for health-related expenses. Some generous employers even make contributions to your account. You would submit receipts for expenses not covered by insurance for reimbursement.
For people who participate in a high-deductible health plan, an HAS may be an option. This is another type of tax-exempt account you set up and maintain, although some employers may make contributions, too. You’re even allowed to invest your HAS monies to earn tax-deductible interest. For more information, contact the IRS or check out www.irs.gov to learn more. Also note that beginning in the 2005 tax year, the IRS allowed taxpayers to deduct medical expenses for a limited number of CAM services and products. Please check with your tax preparation professional about this option.
In some cases, the federal government may help with some of the health expenses for CAM treatments. You’ll need to check with each agency to learn about your benefits. Some assistance may be available from the Department of Veterans Affairs, Medicare, or Medicaid (depending on your state’s guidelines). The National Center for Complementary and Alternative Medicine does not provide financial assistance, but it may be possible to participate in a clinical trial for a CAM therapy. To learn more, you can visit http://nccam.nih.gov/clinicaltrials/.
This article is excerpted from the book UnBreak Your Health by Alan E. Smith. For more information, visit http://UnBreakYourHealth.com/.
