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Dear Mark: Insurance and Alternative Therapies

Posted Nov 23 2009 10:00pm

acupuncture Dear Mark: Insurance and Alternative Therapies One benefit of the national debate over health insurance is the spotlight on health care itself. I don’t pretend to have the answer to the political quagmires, but I have to say I’ve enjoyed the deliberation (most of it anyway). Most of all, I appreciate seeing health care issues hashed out in a wide public forum. (I’m holding out hope that it will lead to a real discussion of genuine health itself. A few public figures have tried to steer it that way to little avail so far.) While politicians and talking heads bicker and vent, I tend to take more interest in the stories of independent-minded people who’ve learned to steer the system in their favor, those who’ve fought it tooth and nail and those who’ve checked out of it altogether to go their own route. (Gee, no one fitting that description here … wink). In the last year I’ve gotten a good number of emails from folks trying to do just that – navigating the health care system and their insurance companies as they take charge of their health and buck CW in favor of what they consider more effective interventions that complement their Primal journeys. Here’s one such message…

Dear Mark,

As someone who’s suffered from chronic back pain and arthritis for years, I’m exploring alternative medicine now but finding it impossible to get my insurance company to help pay for it. I’ve taken up the Primal Blueprint lifestyle, which has made a difference in my symptoms, but I know I need to take it to the next level. Conventional treatments haven’t done much of anything for me. I’d love to hear your advice.

Alternative treatments are known in the health community as CAM (complementary and alternative medicine). CAM therapies include treatments like chiropractic care, massage, meditation, biofeedback, movement therapies, yoga, diet therapies, and non-vitamin/mineral supplements. It’s estimated that some 38% of American adults used at least one form of CAM in 2007. Obviously, we live in a free society where people can choose to undertake whatever treatment course they deem desirable. The controversy comes, warranted or unwarranted, when someone is asked to pay for the choice. The New York Times just ran a story about a woman with cancer who, told there was no solution, took the bull by the horns and pursued a course of integrative treatments that saved her life. Her next fight was then battling her insurance to cover the treatments that led to her recovery.

As the Times article notes, she isn’t alone. As CAM therapies – for chronic lifestyle conditions to immediate life-threatening diseases – become more popular in patient and physician circles, there’s more pressure for insurance companies to reconsider their stance on reimbursement. Even government officials joined the debate recently, pushing for certain CAM coverage changes in insurance regulations.

The National Center for Complementary and Alternative Medicine offers recommendations for those seeking financial assistance in covering their CAM expenses. When it comes to maximizing the possible coverage offered by your current health insurance plan, NCCAM suggests first examining your policy to see which treatments are covered specifically for your particular health condition and what restrictions are imposed (higher co-pay, visit limit, etc.). Find out if pre-authorization is required or if you need a referral from an in-network physician for these services. You can also talk to your present insurance company to see if they offer policy riders, (coverage add-ons) that cover CAM therapies.

If insurance doesn’t cover CAM and you’re going to pursue the treatment anyway, you can always try to fight the good fight. Cover your bases by getting a physician referral, using a state licensed CAM practitioner (preferably associated with a conventional health provider office), and asking him/her to write a letter to the insurance company describing the treatment course and its value for your condition. Make the case by then including whatever solid published research you can find showing the treatment’s demonstrated effectiveness for your condition. Also, check out the respective professional association for your particular CAM treatment. As the NCCAM notes, oftentimes these associations keep track of insurance issues related to their field: who covers or reimburses for what, etc. If you’re fighting a claim that’s already been denied, talk with the provider’s billing staff about how the treatment was coded on the claim.

If you’re using CAM treatments without any health insurance (or efforts to get your policy to cover them), consider other ways to lower your cost outlay. Flexible Savings Accounts and Health Savings Accounts allow you to use set aside funds for certain CAM treatments. Be sure to talk to a representative to get the full details on coverage and conditions.

Finally, just let me say that I realize not every alternative therapy can or should be covered. Indeed, a good many are questionable at best, and just as many are wholly bogus. Critics complain there isn’t sufficient scientific proof that CAM therapies work. Truthfully, this is an argument I understand and appreciate on a theoretical level. Even the treatments that appear most promising are frequently supported by smaller studies of less than stellar design. Nonetheless, when you know a thing or two about science, you realize that the actual practice too often differs from the theoretical principle. Plenty of Big Pharma’s solutions don’t exhibit any more effectiveness than some CAM treatments. Sure, Big Pharma has the money to set up large studies and then ghostwrite seemingly objective articles that get big press. The fact is, CAM therapies don’t have big industry dollars behind them. That doesn’t change my view of the studies themselves, but it leads me to at least suspend disbelief on some level.

Science is science, but I guess the contrarian in me is a little more sympathetic to alternative/complementary treatments that show initial promise and need to be studied more rigorously than I am to many conventional treatments that have a well-funded agenda (and massive lobbying power) behind them. I’d argue that just as many conventional treatments (particularly pharmaceutical interventions) are questionable or outright bogus as the most suspect CAM therapies. Just a couple weeks ago, research showed that a simple niacin formula was more effective than Big Pharma’s Zetia in preventing artery plaque. There’s also the issue of cost. Many drugs cost upwards of $10,000-20,000 a year. Drug companies will pay for these no questions asked. Alternative therapies that might add up to a $1000 or less in a given year for the same condition aren’t even considered. It’s a drop in the bucket for a big insurance giant but a potential budget-buster for many folks.

Let me what you think. Do you have tips, experiences in this arena? As always, thanks for the great questions, and keep ‘em coming!

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