Healthcare Coverage & Alternative Medicine

According to the National Center for Health Statistics, about a third of Americans use some form of complementary or alternative medicine (CAM). Americans spend more than $30 billion annually out-of-pocket on everything from acupuncture to Zyto scans. Despite those billions of dollars spent on CAM therapies, many are not covered by health insurance. In the most recent study, most of these out-of-pocket expenses (over $14.7 billion dollars) went to CAM therapies, such as acupuncture, chiropractic care and massage. We spent another $12.8 billion on natural products, and $2.7 billion on self-care approaches, such as wellness books and homeopathic medicines. According to the National Institute of Health (NIH), the most commonly covered CAM therapies include acupuncture, chiropractic care and massage. Non-covered CAM therapies generally include herbs and supplements, homeopathy, kinesiology, and naturopathy. Though these procedures may not be covered, alternative healthcare costs could be reduced if policyholders better understood insurance policies and options, taking advantage of covered CAM therapies.

Many self-insured plans (insurance through employers) offer coverage for a variety of CAM therapies; however, policyholders are often unaware of these benefits and don’t know where to look for coverage information. To make matters more complicated, insurance companies will often require diagnosis and procedure codes before they can confirm coverage. Most CAM providers do their best to verify coverage in advance. However, we’ve had patients come to us from other clinics with stories of being hit with big bills later because their insurance company verified coverage or listed it in the policy manual but failed to mention coverage was limited to specific health conditions or was only partially covered. Being told "yes" to a benefit but not being told about restrictions or limitations leads to large and unexpected out-of-pocket costs that might have been avoided were more detailed information given or obtained. Having the correct diagnosis and procedure codes handy when calling insurance companies and asking about specific restrictions is vital to proper verification, and even then, there are challenges. Like many CAM providers, we've hired a CAM billing expert to handle verifications and billing for our practice (it's that complex).

To paint a picture of how convoluted the process can be, here are a few of the more frustrating restrictions on acupuncture we've seen through our verification process: Unlimited acupuncture visits. Seems straightforward enough, right? Nope, after the claim was denied it was revealed that acupuncture was only covered when provided in lieu of anesthesia for a covered surgery and only when performed by an anesthesiologist. Seriously? Who would even think to ask about such a restriction and is there even a hospital in the US that would allow it? And who would want it? I'm an acupuncturist and I'd prefer not to be put 'under' for surgery with acupuncture and quite frankly, I wouldn't even know how to do that. Over the years I've seen this one quite a bit, which is why our billing agent specifically asks about this restriction. We've never been able to get a solid answer on why this restriction is written into policies as it seems to violate the spirit of the benefit, but this is a battle policyholders will have to fight (and should). Only one acupuncture visit allowed per year. While it's nice that acupuncture was offered on this plan, the benefit is nearly useless. It's much like providing a single antibiotic pill and wondering why the infection didn't clear up.

Acupuncture, while an effective therapy, is unlikely to produce total resolution of any health issue with a single treatment. An acupuncturist cannot provide acupuncture. Another restriction we've seen is acupuncture only being covered when performed by a dentist (yes, really) and some policies will only cover it if it's provided by an MD and on others only by a chiropractor and on a few occasions, it was limited to a physical therapist. Because of this, our billing agent always asks if the acupuncture is covered when performed by a licensed acupuncturist because this information is rarely provided without the question being asked. Such restrictions may be a violation of The Non-Discrimination in Health Care provision, section 2706 of the Public Health Service Act as added by the Affordable Care Act, which expands the types of specialty services that health plans cover. As of January 1, 2014, complementary and alternative medicine (CAM) providers can submit claims on behalf members for services that are:

1. Covered by the member's plan,
2. Within the scope of their licensure/certification as defined by the state statues, and
3. Medically necessary in accordance with state statutes.

Coverage will be based on the member's existing plan benefits and all other terms of the member's plan, including but not limited to medical and payment policy criteria.The provision applies to all plans that include the changes mandated by the Affordable Care Act for 2014. It doesn't apply to Medicare Advantage, grandfathered, or transitional plans. Note: In November 2013, federal and state governments allowed members with small business and individual plans to keep their existing plans for 2014. These transitional plans don't include the law's new coverage requirements. Coverage Codes for Affordable Care Act lists coverage codes for all medical plans that cover benefits rendered by CAM providers. No insurance coverage? One option for obtaining coverage for alternative medicine costs is through a Health Savings Account (HSA), Flexible Spending Account (FSA) or Healthcare Reimbursement Account (HRA). For more information on these options, visit: https://www.consumerreports.org/healthcare-costs/how-to-use-fsas-hsas-hras-to-cut-healthcare-costs/

The good news is that each year more insurance companies are covering evidence-based CAM therapies. There are bound to be glitches and complications as the healthcare industry adjusts, adapts and grows. Be patient, do your research, challenge policy restrictions that don't seem right, call your congressman or representative. Change is happening but only because Americans are reaching out and making their voices heard.