Disease Care vs. Wellness Care & Insurance

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Medicare Guidelines

Did you know that your insurance company operates under the Medicare Guidelines? Medicare Guideline, Section 2251.3 reads: “A treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy is performed to maintain or prevent deterioration of a chronic condition is deemed not medically necessary.”

What Doses Medically Necessary Mean?

"Medically necessary’ refers to ‘reasonable procedures for the diagnosis and/ or treatment of injury or illness’.”

In other words, it refers to the management of symptoms, not the overall resolution of the condition. Thus, as described by these guidelines, insurance will not cover treatments which correct a dysfunction or imbalance.

In this short video we’ll more thoroughly address what this statement means by identifying the difference between wellness care - the kind of care that keeps you out the hospital - and disease care. We’ll also talk a little bit about what you can expect from office visits. The purpose of this video is to offer knowledge which will empower you as you move forward to reach your health goals.

Health Care vs. Disease Care

To be effective, we first need to define health-care and disease care. According to Merriam Webster, health-care is defined as “efforts made to maintain or restore physical, mental, or emotional well-being . . .” This is contrary to what traditional medical care will provide. Which leads us to disease care or, rather, the care covered by your insurance.

Insurance Visits vs. Comprehensive Visits

Insurance Visits

During a comprehensive visit however, we look at you as a whole person and evaluate all aspects of your health and life. This means we simultaneously look at your stress level, your mental/emotional health, your physical health, as well as the biochemical aspect of your health. This aides us in determining the root cause of your symptoms so that, together, we can work to eliminate them altogether, and bring the body back into balance. 

Comprehensive Visits

As stated, disease care is simply symptom management. Therefore, during an appointment for which insurance will be billed, the focus will be solely on your sxs and finding ways to only reduce them through natural remedies or pharmaceutical medications, when necessary; but no treatment or therapy can be offered which will seek to rid your body of them. It’s also important to note that while your insurance plan most likely covers pharmaceutical medication, they will not cover any portion of the cost of natural remedies. This does not include flex or health spending accounts, of course, as most allow you to purchase natural supplements.

What Your Insurance Covers

I’ll elaborate a bit: If the underlying issue of anxiety, for example, stems from a stress or trauma experienced in the past, or from some fear of the future, your insurance will not cover the process to identify either of these reasons for your anxiety. Rather, the standard of care when using insurance, is to provide you with an anti-anxiety medication. Again, this means insurance only covers disease management. With that said, however, the natural remedies we have available for anxiety, which can be offered through an office visit covered by your insurance, will serve to get you well in most cases, it will just take a great deal longer to reach optimal health and will only address one aspect of your health. Therefore, the natural remedies will only manage your symptoms. But a comprehensive visit will allow us to provide treatments and therapies which address and correct the reasons for your anxiety, on top of the natural remedies. In conjunction, they serve to promote healing, relief, and balance at a much faster rate. 

You Are Worth the Investment

So, just a quick final note before closing: We live in a toxic world. It’s highly important to understand that acquiring wellness or optimal health requires an investment of time and resources. We encourage you to ask yourself the following questions:

When was the last time I spent money on my car to ensure it continued operating optimally?

Do I make myself a priority and look at my health as an investment in my future, my freedom, and my enjoyment in life?

Your answers to these questions, together with the knowledge of health or wellness care as it’s compared to disease care, will help empower you.

You are worth the investment.

In this lesson I explain the difference between disease care and wellness care. Please watch the video through to the end and then continue to the course survey and attestation lesson.

Insurance FAQs

Which insurances are accepted?

  • Blue Cross/Blue Shield
  • United
  • Regence
  • First Choice
  • Premera (major plans through Premera BC/BS Network which includes Global, Heritage, Foundation, Heritage Prime and Heritage Signature Networks)
  • Premera LifeWise Assurance plans
  • Premera LifeWise Health Plan of Washington (which includes LifeWise Preferred and LifeWise Connect networks)

If you don't see your insurance provider on that list, please contact us. We are constantly improving our office to best meet your needs, and this list is not all inclusive.

What kind of care is covered by insurance?

Only the services related to the management of your symptoms are covered by insurance. Thus, these are the only services for which we're able to submit claims to your insurance for. These appointments would include those wherein time is spent to determine medications or supplements appropriate to your individual needs.

Our comprehensive services—also referred to as energy work visits— are not covered by insurance. These are the services which "prevent disease, promote health...prolong and enhance...quality of life....[and] maintain or prevent deterioration of chronic condition[s]" under the medicare guidelines. These are the services that help fix the root cause of your symptoms. These services include TBM (Total Body Modification), EFT (Emotional Freedom Technique), NET (Neuro-Emotional Technique) and others. These effective techniques allow us to "follow the body" in order of most antagonistic imbalance to the least to dig deep and help reset and correct the body's imbalances.

How are my claims submitted?

We are happy to submit claims on your behalf. However, Washington State Insurance laws mandate that it is your responsibility to know your insurance coverage and ensure your doctor’s office has accurate information to be able to submit those claims. Thus, please ensure that you closely adhere to the instructions on the "Insurance Information Submission - WA Practice Mgmt" intake document after you set up your patient portal.

This document is used to submit your insurance information to our third party billing agency Washington Practice Management Service. They will manage your insurance claims and billing from us– and we'll cover all the costs of submitting that information to them. We want getting good health care to be easy, simple, and painless for you, so we're willing to take that cost on to give you the best possible experience.

For all patients wishing or needing to submit claims on their own, we ask that reception be informed ahead of time as additional forms must be signed and extra information must be collected.

What is Washington Practice Management Service?

Washington Practice Management Service is our third-party billing agency that assists all potential and established patients with their insurance needs. Their staff work hard helping each patient fight for reimbursement in the event of any erroneous denials. They also give patients quotes on what naturopathic coverage they have at no expense. These quotes do not guarantee coverage. Overall, when the claim is processed by the insurance company, it is their decision what they will reimburse based on your insurance plan benefits and coverage.

What if my insurance is owned out of state?

If your insurance is owned out of state, that state has the overall say as to whether or not they will uphold Washington state guidelines for your naturopathic insurance coverage. In these cases, you are responsible for payment of your bills and you will need to appeal your insurance personally.

Can I use funds from an HSA/ Flex Plan?

Yes. We ask that patients let us know ahead of time that they will be using funds from a Health Saving Account (HSA) as extra time is required to prepare necessary documentation. Patients will need to keep this documentation on file should he/she be audited. Please note that a $5 clerical fee could be charged for the documentation. Please call and notify us if you plan to go this route.

If you find you still have questions about billing & insurance or about which kind of care is covered by insurance, please call our office.

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