Category Archives: Medical Business

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Insurance – “Medical Necessity” Requirement Part 2

Services:  What does the requirement of  meeting “Medical Necessity” mean? 

What it does not mean is what your doctor thinks is beneficial or necessary.  No, the insurance company decides if recommendations meet community standards which are encompassed in the field of traditional medicine or medical literature reviewed by peers only.

If you see the doctor for a condition or illness that does not include a primary diagnoses, the service cannot be billed at a level that meets coding requirements and will be denied.

Conditions such as yeast infections, depression, anxiety, psychiatric codes, heavy metal burden, multiple chemical sensitivity, erectile dysfunction and many others are not primary diagnoses codes.  Irritable Bowel Syndrome is a primary code (criteria must be met for this as with diarrhea and constipation.)  Gas and bloat are not primary.

Some patients arrive at the doctors office with a short list, wanting only a specific condition addressed.  When this happens, it may automatically set the course for denial by the insurance company.  The insurance company wants to see primary diagnoses codes which are define by a coding standard.  Requirement for correct billing is an appropriate ICD-9 code or billing code and a primary CPT code.  

Uncovered codes are patient responsibility if waiver is signed.  Before you leave the clinic with a laboratory test, we will provide you with the cost of the test and the extent of what we believe your insurance will pay.  That amount will be collected at the time of service.   We cannot guarantee your benefit amount because your insurance will not guarantee the information received when we call and verify benefits.  They state and our business agreement states that you solely are responsible for bill regardless of your insurance coverage.

Sample Profiles (list not complete for covered and uncovered tests):

Pesticide Panels:   You must provide a payment for the total billed to the laboratory.  We can then bill your insurance company, later refunding you if coverage is accomplished. 

Amino Acid Assays, Nutritional Based Assays-most insurance companies do not pay these items, however, through an agreement with the laboratory, we can accomplish quality assays for amino acid serum, RBC mineral, organic acid and fatty acid profile for a very low cost.

Genetic Testing-.While this is not a covered expense at this time, there is talk that it may be in the future.  You should consider, if that benefit becomes available, the consequences your genetics may have on life insurance, for example.  

Comprehensive Detoxification Panel:  Portions of this tests are not covered by insurance, therefore, unbilled portions are paid to the patient.  We notify you what we believe your responsibility will be.

DMPS Chelation Therapy and Metals Challenge Test-Does not meet medical necessity and is therefore paid by the patient.  See next segment.

EDTA Chelation Therapy and Metals Challenge Test-We use this therapy for reducing specific heavy metal burden.  Because the conditions we treat are due to chronic exposure, only on rare occasions does insurance ever pay.  Payment is always due date of service.  Toxicity is defined by blood test only and is rarely seen in patients with acquired body burden.   The appropriate test in this case usually will not qualify you to meet medical necessity.  Payment in full is required by the patient.

Environmental Pollutants-We will not bill for this service as most of it is not covered by insurance, therefore, paid in full by the patient.

Food & Inhalant Testing-covered if qualified.  Qualifying a patient includes ages under four, autoimmune disease and chronic skin conditions such as eczema or psoriasis where the doctor believes skin testing may worsen the condition, chronic use of antihistamines without benefit and steroid use.

Hair Analysis-We will not bill for this service as  it is not covered by insurance, therefore, paid in full by the patient.

Vitamin Mineral IV’s-generally not covered and PPO insurances requires that you provide documentation after the service is performed to see if it meets medical necessity.  Therefore, we require payment upfront with a waiver.  In almost every case, insurance does not cover. 

Nutritional Consults by Certified Nutritionist-typically uncovered. 

Other tests such as the ION and TRIAD panel by Metametrix is payable in advance.  We will then bill your insurance company and refund any portions paid.  

Stool Testing:  Payable if criteria is met.

Center for Environmental Medicine

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Insurance – Medical Necessity – Part 1

Center for Environmental Medicine is a medical practice providing health care to families and individuals from a holistic approach; applying therapies studied from allopathic (conventional or contemporary medicine whose practitioners prefer to claim “The Standard of Care”), alternative, integrative, complementary and functional medicine or CAM.  These services in the health insurance industry may sometimes fall under the category of “not medically necessary” and is further addressed below.  This is true for all practices.  Additionally, with strictly conventionally practices you will see tests and services that do not meet medical necessity.

The ultimate purpose of our work is to serve and help people regain health and sustain wellness.  Our vision is to create a center that seeks to reach out to the public, to assist in the healing process through detoxification and restoration of the inherent balance in the body with the safest therapies available. Ultimately the goal is to treat the whole body which includes emotional and spiritual health. Our methods may include nutritional biochemistry, lifestyle modification, bodywork, chelation therapy, and bioenergetics.  We address target amino acid which ultimately accesses the balance of neurotransmitter and adrenal support. We provide diagnostic laboratory tests including esoteric tests not generally accepted by mainstream medicine.  We seek to exchange ideas, educate and assess all with a holistic, open-minded and functional medicine approach.  Every member of the health care team, which includes the patient, must understand when we give our best, then we ask for a patient who comes with integrity and interest in resolving their health issues. 

Many people look to their insurance in helping to meet their health care needs.  While we cannot guarantee coverage, we have a good understanding of what information insurance is seeking in order to process a claim efficiently, accurately, and to the benefit of the insured.  We will ask for assistance from the patient in providing supportive assessments related to history which is how we accomplish meeting strict requirements by the insurance company to meet medical necessity.  To be clear, it isn’t always possible.  When insurance is not available, we provide the patient with viable options which may help to accomplish their goals.

The term “medical necessity” is often misunderstood by the patient.  Understanding the definition of this term prior to medical treatment often relieves a patient of frustration as they plan their strategy of an affordable health goal. 

From Wikipedia, a free web encyclopedia related to medical information, medical necessity is a legal doctrine related to activities which may be justified as reasonable, necessary, and/or appropriate, base on evidence-based clinical standards of care.  Definitions to each plan are outlined within the insurance contract to the individual consumer. 

The insurance company may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury…”  Your doctor may have a different opinion outside of this definition based on his clinical experience and scope of practice.  While the insurance company’s goal is to cover specific benefits only, the doctor’s goal is to achieve your healthcare goals. Your insurance company allows for your right to choose the type of care you select, but they reserve the right to make the final determination if they will pay for a service or not.  Ultimately, it is your responsibility to understand what your insurance benefits are. 

Benefits are based on the patient’s specific contract.  Co-pays by law are due before insurance can be billed.  In some cases, a laboratory test may be only partially covered.  In all cases we tell a patient in advance that we do not guarantee coverage, inform them what is usually not covered and allow them to make the choice of how they approach their health.

Center for Environmental Medicine