The Pitfalls of Filing Insurance

The other day Jiang Li, our very popular Chinese doctor, inquired about joining an insurance network. She wanted to know if I belonged to any and what I thought about being a provider. I thought it might be an interesting topic to share with the general public.

Now, I'm not sure about how it is with acupuncture, but I can tell how it is for me. The one advantage I can think of is the possibility of increased exposure to policy holders. As I thought more about it, I found quite a few disadvantages.

One problem is that the insurance companies beat you up so bad. Allow me to explain. If you are an out of network provider, the deductible and co pays are significantly higher for clients than if you were “in network”. This effectively inhibits seeing the out of network provider. If, as a practitioner, you are “in network” you must agree to whatever terms the insurance company sets. Part of the agreement with the insurance company is that they're setting the “allowable” fee which, by the way, can be about 50% of the normal fee. The difference can not be charged to the policy holder, so the doctor eats it. In addition the time involved in verification, processing and follow up significantly raises a doctor's employee overhead. In our office, Mindy was spending so much time within that arena that it took time and energy away from taking care of the clients. (And me. :-))

The increased overhead is easier to absorb if your practice lies more in the therapeutic realm because you can add and bill for a number of other modalities each visit, including heat, ice, muscle stimulation, and therapeutic exercises. For the consumer that can mean a 30% co-pay on one hundred plus dollars instead of forty which will bring the co-pay up to and past the original forty dollar office visit.

Last but certainly not least is the simple fact that “health” insurance (it would more accurately be called disease insurance) does not pay for wellness care. Yes, I'm aware that some policies will pay for “alternative therapies." However, there must be a diagnosis and treatment of symptoms which automatically falls outside the realm of wellness. The real problem is the effect this has on the mindset of the practitioner and client.

If we are to render a diagnosis then we first have to make a judgment about a particular symptom. Once we judge the symptom as bad we must find a way to remove it. This is what they call the medical or treatment model, which has absolutely nothing to do with wellness. In fact, if a symptom has manifested to alert a person to the need for change, then treating the symptom would be the antithesis of wellness. That doesn't mean that it isn't ok to have symptoms treated at times. It's just impossible to do both. You've probably heard the saying, “you can't serve two masters." Well, trying to be in the treatment model and the wellness model simultaneously would be doing just that.

Over the last twelve years of practice I have noticed something very interesting. In general, clients who had insurance pay for their care did not get as good results as clients who didn't. I believe this to be due to fact that it perpetuates the idea that we are being fixed by the doctor instead of taking control and responsibility for our own healing process. In wellness the practitioner becomes the facilitator, not the fixer.

Working in the insurance game, and in the treatment model, undermines the fundamental understanding of wellness and it quite simply comes down to this: It's a game I can't win.