FAQ's About Insurance Coverage

Why do you need my insurance card if you don’t bill my insurance for my visits? 

 

Frequently Asked Questions about insurance coverage:

 

The quick take-home points are:

• Having your accurate insurance information helps us make sure you get the coverage you are entitled to for the medical services ordered.

• Coverage is not guaranteed simply because a doctor orders it.

• “Covered” does not mean free or low-cost.

 

Just about every medical service we order for you will get billed to your insurance: laboratory tests, imaging, pharmacy medications, and referrals to specialists. Having your accurate, current health insurance information helps us to help you! Most people will receive a new card annually, around the first of the calendar year. Please compare the new card to the old card closely and let us know if there are any changes, especially with member numbers and group numbers, and preferred pharmacy information.

 

Some specialists only accept certain insurance plans, so we want to make an efficient referral. 

 

Imaging tests like MRI and CT scans often require a “Prior Authorization” before we can send the order to the imaging center that will perform the test. Likewise, some prescription medications require a Prior Authorization for your insurance plan to determine if your medication will be covered. We must know what insurance plan you have so we can contact the correct resource for the request. 

 

It is ultimately your responsibility to make sure that any facility providing any aspect of your medical care has your most current, complete insurance information so you can receive your benefits and the facility can get paid for the service provided. Don’t assume they have the correct information if they do not ask - unless you want to get the bill!

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Why wouldn’t something be covered if my doctor orders it?

 

Let’s talk about Prior Authorization and Medical Necessity. 

 

Prior Authorization is a process insurance companies require for some expensive imaging services or medications to make sure the reason for the order meets their medical necessity or plan coverage requirements. It involves our office providing medical information about your condition, symptoms, treatments already done, and what we are trying to determine with the test. This is intended to help prevent fraud and overuse of medical resources but can feel frustrating for everyone involved. This communication is legal under the Health Insurance Portability and Accountability Act (HIPAA) for disclosing only information relevant to promoting continuity of care.

 

Medical Necessity is a predetermined list of circumstances for which a test or treatment could be needed, based on FDA-approved uses for medications and evidence-based guidelines for medical imaging and treatments. 

 

Medicare in particular has many rules around lab test coverage. They only approve certain tests for certain diagnoses. While you and your doctor may have valid medical reasons for wanting to run a test, coverage is not guaranteed even with a physician’s order. We do our best to follow guidelines, but it is your responsibility to check your coverage. For example, Medicare will cover a Vitamin D test if you have a bone disorder like osteoporosis. They will not cover a Vitamin D level to evaluate Fatigue. But, if you have a known diagnosis of Vitamin D Deficiency, they WILL cover the test as long the ordering provider uses that specific approved diagnosis code on the order. Medicare may also only cover tests at certain intervals, based on medical guidelines, like a Hemoglobin A1c every 3 months for monitoring Diabetes, or a DEXA bone density test every 24 months to monitor osteoporosis. 

 

Medical insurance plan coverage varies for a number of reasons: your employer chose certain care categories to be included or excluded in the plan they offer employees; Medicare has specific coverage rules; Medicaid has specific coverage rules that may vary by state; Medicare Advantage plans cover everything that “traditional Medicare” covers, plus other benefits that vary by plan. While there are basic coverage requirements, like preventive care and screening services, your employer can choose what is and isn’t covered (“coverage exclusion”) when they contract with the insurance plan.  

 

Medicare does not currently cover lab tests, imaging, or referrals for physical therapy when ordered by naturopathic physicians. This is related to the fact that naturopathic doctors are only granted licensure to practice medicine in some states. (https://naturopathic.org/page/RegulatedStates)  When needed, Dr. Baird and Dr. Suber collaborate so that you have the best possible chance of insurance coverage through Medicare.

  

There have been multiple state and federal legislative efforts over the years to expand the ordering capabilities of licensed naturopathic physicians to align with those of MD’s and DO’s. Please consider supporting these bills when you have an opportunity!

 

Why is my prescription still so expensive if it’s covered?

 

Covered doesn’t mean cheap or no cost, it only means your insurance agreed to pay for a portion of the cost, usually a percentage amount that is outlined in your benefits. A very expensive medication may then still be expensive.

 

Your insurance plan can choose which medications in a certain category are preferred for coverage over others. This is why, for example, your weight loss medication is not covered, but your friend’s same prescription is. Or, your diabetes medicine is suddenly not covered but another medication in the same category is covered.