I’m asked all the time by patients whether certain tests or treatments are covered on their insurance. My answer is, “It depends.” I’d like to write about what insurance mainly covers, what it doesn’t, and perhaps why.
After 27 years of practice now, I’ve seen the changes in insurance plans as well as coverage.
A lot of the coverage has been diminished and the co-pays have increased. Regarding Medicare and a secondary, co-pays are mainly a moot point of course. Here in this article, Medicare is the one plan that has remained mainly the same throughout the years. One thing that Medicare has changed back in the early 2000’s, is Medicare Advantage plans.
So many patients think they still have Medicare when they have a private insurance company instead. Who pays your Medicare claims, Medicare or the private insurance? If you purchase an Advantage Plan, you still have Medicare, but you get most of your part A and part B coverage from your Medicare Advantage plan, not original Medicare. This becomes an issue of coverage in many situations. Medicare will cover certain diagnostics and treatments, and the Advantage Plans should cover the same, but it depends on whether the treating facility is contracted with the private insurance company that manages the Advantage Plan. There are generally more steps to pre-certify the test or procedure, that can take weeks, and still may not be covered in the long run.
Regarding what is covered, and again mainly on Medicare, the basic tests and treatments that have generally been a standard for quite some time are covered. Newer treatments and diagnostics must go through specific processes in order to be approved by Medicare. This is a lengthy process, and generally reflects pharmaceutical and hospital benefits.
So many cutting-edge tests and procedures are not covered as a result. Over the years, I have found that only preventive measures are covered. When I mentioned in the title of this article, that managed care only manages your condition, that’s what it does. I know of colleagues who have worked in large, respected hospitals and left because they claim that they were keeping sick people sick. Most have left to open their own practices that work with functional medicine and other disciplines that actually look for the root cause of the condition, not to just manage it for the patient’s lifetime.
By covering the basic tests and treatments, and in most cases outdated tests and treatments, this keeps the patient on the same medications and the same course of care throughout their life. I find very few conditions are resolved in this type of system. Like all science, medicine is changing every day. The insurance system must change respectively.
As a physician who owns an integrative practice with both medical and alternative, it’s frustrating when patients’ insurance will not cover tests and treatments that are necessary for the patient to get better. I believe some of the greatest frustration is felt by the patient, as they feel they have the best coverage possible and yet they are not getting better, thus the treatments they need are not covered. For many years, I have recommended that patients keep a separate medical fund for procedures that are not covered by their insurance.
I do realize that many people cannot afford to do this. That is the saddest part of all. For those who can, however, they must realize that the best treatments for them will most likely not be covered on their insurance. I tell people to do the math. How many times have you gone to the doctor, different facilities, and the pharmacy? How much is your time worth, and how much have you spent on gas, or relying on others to take you? Once you’ve done the math, you must be honest with yourself and realize how much money has been spent on all of those. Had that money been utilized for cutting edge diagnostics and treatments, your condition most likely would have been greatly improved or even resolved.
It’s a hard fact but true. I’ve seen it frequently over the last 27 years. Relying on what insurance covers is not always the best. It’s good for traumas and basic diagnostics but rarely effective for newer treatments. Most training facilities either do not take certain insurances, or so many of their treatments aren’t even covered. That is quite a shock to the patient.
Today, medicine is changing quickly. There are other countries that offer treatments that are not even available here in the US. And those treatments that are available in the US, are not covered by any insurances. This includes regenerative medicine, specific diagnostic testing, supplementation, and so many more treatments that work so effectively to get to the root cause of the condition and resolve it.
For preventive and resolving chronic conditions, I would recommend understanding that self-pay is most likely going to be the answer.
I truly hope this helps you understand the difference between what’s covered on insurance and what may be the best for you. They are not one in the same. Should you or anyone you know want a complimentary consultation with me, please call my office.
For questions regarding my articles, please email me at DrLeisa@CaringPainRelief.com
Accurate Care Medical Wellness Center
Leisa-Marie Grgula D.C.
18261 N. Pima Rd. Ste # 115
Scottsdale, AZ 85255