Health insurance companies come in three major forms. One is a closed panel HMO (Health Maintenance Organization) where patients can only see doctors in the HMO. This would be like Kaiser Permanente where you can only see their physicians. The physicians are usually employed by the insurance company or some affiliate of the insurance company. These plans generally do not offer reimbursement for seeing a doctor outside of the plan.
Another type of HMO contracts with private doctors for sharply discounted rates, often called a capitation rate. The primary care doctor will get a small payment, maybe $20 per member per month, to provide 24/7 coverage to the patient or roughly $240/year plus copays. Patients can only see doctors in the HMO network and get nothing if they seek services outside of the network.
A PPO (Preferred Provider Organization) contracts with private physicians for a discounted rate. Most PPOs will reimburse some payments for out-of-network providers but with higher deductibles. This gives patients more choices in physicians. Most PPO insurance carriers will have a section on their website about out-of-network benefits.
Medicare is one insurance carrier but doctors have three options on how to conduct business with Medicare. They can participate and accept what Medicare allows for a visit; they can be non-participating, but the government still limits what the doctor can charge the patient; they can “opt-out” which means the only contract is between the doctor and the patient and Medicare is not involved. Medicare still requires that all lab and radiology studies be billed through Medicare.
How insurance does not work
The current structure of the health insurance industry has evolved to pay for procedures and not for thinking and talking to the patient. This reimbursement model persists despite the fact that in medical school we learn that 80% of the time a good patient history will lead you to the diagnosis without any other testing. More medical students choose to go into specialties due to the reimbursement model, which further compounds the shortage of primary care physicians. This deranged payment system has often been driven by the companies that make the latest stent or new piece of radiological equipment. Of course, the doctors in our practice are grateful for new techniques and treatments but one of our goals is for you not to need them.
The financial goal of health insurance companies is to make money for their stock holders by taking in more money than they are putting out. Paying for care now that promotes your health in the long term does not help the insurance companies meet their financial goal. Insurance companies do not look at the cost of providing a service to determine what they will pay for it. They pay the least they can get away with. If you keep up on the current news you know we are in a primary care crisis where family doctors can no longer afford to keep their doors open because of low reimbursement from insurance companies. Study after study shows that a strong primary care base actually decreases health care costs in the long run. But insurance companies are not worried about the long run – only their bottom line this quarter or this year.
Our current health insurance system does not work. It rewards tests and procedures and penalizes physicians who spend time with patients, think about patients and actually try to balance their patient’s treatments and costs of their care.
We don’t have all the answers but we made a commitment to be doctors and healers which takes time and unfortunately costs more than current insurance reimbursement.
How we work with insurance carriers
We, like most integrative medicine practices, are out-of-network providers. As an out-of-network provider, we have not signed a contract for discounted rates with your insurance carrier. This allows us to spend more time with a patient and for you to see a doctor on every visit, receiving the care each patient like you deserves. Unlike other integrative medical practices, we submit your claim to make it easier to get reimbursement from your insurance carrier.
As an out-of-network provider, we are able to provide more service to our patients. Patients who choose our services do so for primarily three reasons.
First, they are tired of the 5 to 9 minute office visit. All of our patients are scheduled for 30 to 60 minutes. This amount of time is unheard of in other offices.
Second, patients choose us because they are tired of just being given a prescription and sent out the door. We will use prescriptions when necessary but realize that most of the time prescriptions are treating symptoms and not addressing the underlying problem. We have skills and knowledge in many healing arts from acupuncture, herbs, nutrition and functional medicine to help you get well with fewer side effects.
Third, patients seek our services when they have sought treatment for months, sometimes years from many practioners for chronic conditions and want someone to look at their whole picture and research causes and treatment options both in conventional and holistic medicine.
For most insurance carriers, we will submit to your insurance and wait thirty days for the carrier to pay. After thirty days, we will bill you any balance remaining. Labs will be billed through our office. Any radiology studies will go through your insurance carrier through a participating radiologist.
For Blue Cross/Blue Shield, you pay for your visit at the time of service and we will balance bill for any additional labs or tests after thirty days. Labs will be billed through our office. Any radiology studies will go through your insurance carrier through a participating radiologist.
For Medicare and Tricare patients, we have opted out of these plans and patients pay for any office visits or in-house tests. For Medicare patients, all other lab tests are submitted directly to Medicare.
We provide unique services as the premier integrative holistic primary care practice in the Washington DC area. Our patients are making an investment in their good health and their future.