Unlocking The Complex World Of Insurance Billing For Functional Medicine

Functional medicine is a holistic approach that focuses on treating the root cause of a disease rather than just covering symptoms with medication. It is a patient-centred approach that combines conventional and holistic medicine. However, functional medicine is not typically covered by insurance. This is because insurance companies tend to focus on the conventional model of healthcare, which relies on drugs and surgery.

While functional medicine doctors do not usually accept insurance, there are still ways to get reimbursed. Some functional medicine doctors are in-network with certain insurance companies, meaning they are recognised by the insurance provider and will be able to bill them directly. If your doctor is not in-network, they may provide you with a superbill receipt, which you can submit to your insurance company for reimbursement. Additionally, some insurance companies offer out-of-network benefits, where they will reimburse for medical care with providers they are not directly contracted with.

It is important to note that insurance coverage for functional medicine can vary depending on individual cases, and it is always a good idea to contact your insurance provider to inquire about holistic medicine benefits.

Billing for face-to-face and admin time

Changes in Billing and Coding Requirements:

Beginning in 2021, there were significant changes to the Evaluation and Management (E/M) office visit coding and documentation requirements. The new changes allow billing for both face-to-face and admin time, providing more flexibility to practitioners.

Face-to-Face Time:

Face-to-face time refers to the time spent directly interacting with the patient during a consultation or treatment. This can include activities such as performing an examination, counselling the patient, and coordinating care. It's important to note that only the time spent with the patient can be counted towards face-to-face time.

Admin Time:

Admin time includes the time spent on activities that are not directly face-to-face with the patient but are still related to their care. This can include activities such as preparing for the patient's visit, ordering medications or procedures, communicating with other healthcare professionals, interpreting test results, and documenting clinical information in the patient's electronic health record.

Choosing Between Time-Based and Medical Decision-Making Coding:

Practitioners have the option to bill by time or by medical decision-making (MDM). Time-based billing is useful when spending a significant amount of time with the patient, while MDM billing is more appropriate when managing multiple chronic illnesses. The choice between the two methods can be made on a patient-by-patient basis.

Meeting MDM Requirements:

To qualify for a specific code, only two out of three elements of MDM need to be met. These elements include the number and complexity of problems addressed, the amount and complexity of data reviewed and analysed, and the risk of complications or morbidity associated with patient management decisions. Social determinants of health, such as housing and economic circumstances, can now be considered in meeting the complications risk element.

Insurance Coverage for Functional Medicine:

It's important to note that functional medicine may not always be covered by insurance. Many functional medicine practices charge fees directly to the patient, as they may not be reimbursed by insurance companies. However, some insurance plans, such as "out-of-network" plans, may provide reimbursement for out-of-pocket expenses incurred during functional medicine treatment. Additionally, Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) can often be used to pay for functional medicine services.

Using out-of-network plans

If you are considering using an out-of-network plan to cover your functional medicine costs, there are a few things to keep in mind. Firstly, understand that out-of-network costs can add up quickly. When a doctor or facility has no contract with your health plan, they are considered out-of-network and can charge you full price. This price is usually much higher than the discounted rate you would get with an in-network provider.

In some cases, you may have to pay the difference if the doctor's bill is higher than what your plan will pay. Many health plans will specify the maximum amount they will pay for a certain service received out-of-network, and you could be responsible for any amount charged above that, in addition to your deductible, copay, and/or coinsurance. It is important to note that there are no copays when using an out-of-network doctor or facility, but you are responsible for paying the coinsurance, which is typically a higher percentage than the in-network copay or coinsurance amount.

To avoid unexpected medical bills, it is crucial to familiarize yourself with your plan's benefits and limitations. Understand what services are covered and what your financial responsibility will be if you choose to see an out-of-network provider. Some insurance companies will reimburse for medical care with out-of-network providers, clinics, and health systems, which is known as "out-of-network benefits". However, there is no guarantee of reimbursement, and you may need to meet a separate deductible for out-of-network services if you have a high-deductible health plan.

If you are considering using an out-of-network plan for functional medicine, be sure to check with your insurance provider to understand your specific coverage and benefits. Additionally, some functional medicine practices may provide you with the necessary insurance codes and paperwork to submit to your insurance company for potential reimbursement.

Understanding your insurance benefits

Understanding Common Insurance Terms

Insurance policies often use technical terms that can be confusing. Familiarize yourself with commonly used insurance terminology such as "premium," "deductible," "copayment" or "copay," "coinsurance," and "network." Knowing these terms will help you better understand your coverage and benefits.

Know Your Coverage Limits and Exclusions

Different insurance plans have varying coverage levels. Expensive policies usually offer higher coverage limits, but at a higher cost. It's important to know what specific services and treatments are covered by your plan and what exclusions or restrictions apply. For example, some plans may not cover certain prescription drugs or mental healthcare services.

Understand Your Out-of-Pocket Costs

Out-of-pocket costs refer to the expenses you are responsible for paying yourself. These include deductibles, copayments, and coinsurance. Understanding these costs will help you anticipate your financial obligations when seeking medical care.

Explanation of Benefits (EOB)

After receiving medical care, your insurance company will send you an Explanation of Benefits (EOB) statement. This document details the services provided, their charges, and how your insurance company processed those charges. Reviewing your EOB can help you track expenses and ensure you're not overcharged.

In-Network vs. Out-of-Network Providers

Your insurance plan will typically have a network of contracted doctors, hospitals, and suppliers. Using in-network providers usually results in lower out-of-pocket costs. Going out-of-network may result in higher expenses, but some insurance companies offer "out-of-network" benefits, where they reimburse you for a portion of your out-of-pocket expenses.

Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA)

If you have a high-deductible health plan, you may be eligible for an HSA or FSA. These accounts allow you to set aside pre-tax dollars for qualified medical expenses, giving you more control over your healthcare spending.

Open Enrollment and Special Enrollment Periods

Open enrollment is the period when you can start, stop, or change your insurance plan. It typically occurs once a year, but special enrollment periods may be triggered by qualifying life events such as job changes or marriage. Knowing these periods will help you make timely adjustments to your coverage.

Using Insurance with Functional Medicine

Functional medicine often involves a more personalized and holistic approach to healthcare, which may not always be covered by insurance. However, some functional medicine doctors do accept insurance, and you can explore "out-of-network" options or use HSA/FSA funds to pay for your care.

Using health spending accounts

Health Spending Accounts (HSAs) and Flexible Spending Accounts (FSAs) are available to people with a high-deductible health plan. In these accounts, pre-tax dollars are placed directly into an account for you to use as you choose for your medical care.

There are certain rules and regulations about what you can spend this money on (consult your health insurance guide or check the rules online), but for the most part, doctor visits are allowed. Lab tests, certain medications, and even supplements can also be covered.

Many functional medicine practices encourage the use of your HSA or FSA dollars to pay for your care if it is available to you. It can be a simple way for you to receive the kind of care you are seeking.

Some functional medicine doctors do not accept insurance as payment for treatment. However, they may be able to give you a superbill for pay-per-visit appointments, which can be turned into your insurance company for reimbursement (if you have holistic medicine coverage). They may also accept HSA cards.

If you are using an HSA or FSA, you will need to submit a claim to the relevant account (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you will get reimbursed for your costs. Ask your employer about how to use your specific account.

It is important to note that FSAs are "use or lose", meaning that the amount in your account will expire at the end of the year. However, employers can offer a grace period of up to 2.5 extra months to use the money in your FSA, or they can allow you to carry over a limited amount of funds into the following year.

In-network vs out-of-network

When it comes to billing insurance for functional medicine, understanding the difference between in-network and out-of-network providers is crucial for managing your healthcare expenses. Here is a detailed overview:

• In-network providers have a contractual agreement with your health insurance plan, agreeing to accept pre-negotiated or discounted rates for their services. These providers are part of your insurance plan's network and have met certain credentialing requirements. By using in-network providers, you benefit from lower costs as the insurance company has more control over the rates charged. You pay a copay, which is a fixed amount, and the insurance company covers the rest as per your plan.
• Out-of-network providers, on the other hand, do not have a contract with your insurance company and have not agreed to accept negotiated rates. If you choose an out-of-network provider, you may be responsible for paying the full amount charged by the provider. Your insurance plan might cover a portion of the bill, but you will likely have higher out-of-pocket expenses. Out-of-network costs can add up quickly, even for routine care, and you may end up paying thousands of dollars more if you have a serious illness or injury.
• Most health insurance plans require or strongly encourage the use of in-network providers to keep costs down for both the insured and the insurer.
• In an emergency, you should seek the nearest medical help, regardless of whether the provider is in-network or out-of-network. All health insurance plans typically cover medically necessary emergency services, and the Affordable Care Act (ACA) requires insurers to cover emergency care as if it were provided by an in-network provider.
• If you have a preferred doctor or specialist who is out-of-network, check with your insurance company to see if they offer any coverage for out-of-network providers. Some plans, like PPOs, include out-of-network benefits, but you will generally pay a higher percentage of the cost.
• To avoid unexpected bills, familiarize yourself with your insurance plan's benefits and limitations. Know the difference between in-network and out-of-network coverage, and always verify if a provider is in-network before receiving treatment.

Frequently asked questions