Insurance Questions

Healthcare in the United States is changing for all of us. More people are obtaining insurance, and at the same time many are changing policies either because their rates increased or decreased. For more information about the Affordable Care Act, please follow this link.

Because our clinic is different from traditional models, we often get questions related to insurance. We have compiled a list of frequently asked questions below to help you in your decisions and to obtain maximum reimbursement if possible.

Frequently Asked Insurance Questions:

Is Integrative Family Medicine of Asheville ‘outside' of the insurance model?

In order to provide our quality of care and length of visit at such affordable prices, we do not bill insurance. We do provide all of the documentation for you to submit for reimbursement yourself; however, services at IFMA are not billable to Medicare/Medicaid. This model pairs quite well with high deductible insurance plans such as the ACA Bronze level plans. Depending on your situation, this combination may provide better care for significantly less than a more comprehensive plan (Silver, Gold, or Platinum.)

What is the benefit of changing our relationship with insurance companies?

According to an article by the New York Times, the interface with insurance costs practices over $82,000 per physician per year. This expense raises overhead to such an extent that many primary care physicians do not break even until their 20th patient of the day. This necessitates seeing more patients per day, shorter visits, and less comprehensive, less personalized care. It leads to treating the symptoms instead of the roots of illness, increasing medication usage, and prohibiting time needed to treat the whole person. Studies have repeatedly shown that longer visits yield better outcomes. By not billing insurance we can see fewer patients, provide longer visits, and address the roots of your concerns in personal ways that lead to sustainable health.

Our clinic is a hybrid of Integrative Medicine, Public Health, and a business model known as Direct Primary Care. You can read more about the business model at these two links: DPC Coalition and DPC on Wikipedia.

Does a membership count as insurance for the Affordable Care Act (ACA)?

The membership provides access to care often not covered under many ACA plans. If you combine your membership with a medical cost sharing plan through Liberty Direct, then you will be exempt from the ACA requirement and you will not be fined.

The membership does not qualify as stand-alone insurance under the Affordable Care Act.

Members often save money by combining our services with high deductible plans or medical cost sharing plans. The high deductible plans serve as ‘wrap-around’ insurance for major events that might require procedures or hospitalization. The membership can take care of your everyday health needs including treating chronic medical conditions. This is similar to using car insurance to cover for big accidents, but paying out of pocket for the routine maintenance and upkeep.

How do I seek reimbursement with my insurance company?

While IFMA does not file costs through insurance, you may submit your in-office charges to your insurance provider (*excluding Medicare and Medicaid) for out-of-network reimbursement. While each insurance company may have different requirements, most out-of-network claims involve completing a simple form—usually obtainable by searching for “reimbursement form” for your insurance carrier—and providing documentation through an itemized receipt or invoice. We can provide all of the required information so that you may submit your insurance claim yourself in an itemized invoice.

The form for BCBS of NC is here.

The form for Coventry One is here.

Please make sure to you alert us at the time of your visit that you are going to seek reimbursement. This helps us organize the materials in such a way as to optimize your reimbursement rate.

How much will I be reimbursed?

Because our visits are significantly longer, involve health coaching, and are more comprehensive, we find that our patients receive excellent reimbursement. The rate of reimbursement will depend on your plan, the deductible, and level of co-insurance for out-of-network providers. To understand this better, visit our page on Understanding the ACA to read about Co-insurance and Plan Levels.

Can I submit my monthly or yearly ILM fees for reimbursement?

If you pay in full for your Integrative Life Membership year when you receive your establish care visit or annual physical exam, we can bill cost for an annual membership (paid in full) as a Comprehensive Physical Exam. This comprehensive exam is included with your year’s membership, and this visit type is eligible for insurance reimbursement at an out-of-network rate determined by your insurance provider.

When paid monthly, membership dues are ineligible for insurance reimbursement since the costs are not associated with specific visits or insurance procedure codes. Furthermore, since establish care and annual exams are included in the membership for a $0 visit cost, when you pay monthly for your membership dues, there is no visit fee which can be reimbursed for those exams. 

By paying for the Integrative Life Membership upfront for the year at your establish care or annual exam (Comprehensive Physical Exam) and submitting for reimbursement, you can recover much of the expense of joining. This is the best both worlds: cost savings and better care. We will provide all of the documentation for you.

Are some insurance plans a better fit?

After hearing stories from a number of our patients, we can advise you that it is worth reading the fine print. While we are not insurance agents, we can relay the experience of some of our patients. Some of the plans, which are typically the most affordable ones, have very limited referral networks and limited routes to receive necessary care should the occasion arise. The plans that fit best with our clinic allow out of network providers to make referrals and prescribe medication.

Can I submit my visits to Medicare or Medicaid?

Due to current legal guidelines, our services cannot be submitted to Medicare or Medicaid for reimbursement. We are able to provide an integrative, holistic health consultation for these patients; however, this is a non-billable service for Medicare and Medicaid. We do have a number of Medicare patients that choose to see us for the quality of care and length of visit that they receive. All Medicare and Medicaid patients are required to sign an agreement stating that they understand that visits at IFMA are not billable to Medicare/Medicaid.

Can I bill my labs through insurance?

As a Direct Primary Care (DPC) practice, IFMA consciously does not bill insurance for lab work or office visits.* If you would like to file any lab work costs with insurance, you may request a copy of your paperwork to submit to your insurance provider for reimbursement. We can make no guarantees concerning rates of reimbursement as they are dependent upon each patient’s insurance provider and plan.

* IFMA will only bill Medicare for lab work that is $60 and up per test (panels excluded). *Panels are comprised of individual tests and therefore not included as billable; only the cost of a qualifying individual test may be submitted. *Excludes specialty and hormone testing; we do not bill Medicare for these labs.

Do you handle prior authorizations?

Insurance companies may require prior approval before performing expensive procedures, diagnostic tests, or prescribing non-generic medications. This is a cost containment measure for them, however it can be very time consuming for medical offices.  Staff may spend a lot of effort faxing, discussing the case on the phone, and conferring with physicians before the item is approved. This process is known as a ‘Prior Authorization.’

Studies have demonstrated that this tactic may decrease overuse of expensive options, though it is a significant expense passed on to medical offices. Since our clinic bills primarily on time, we have the following prior authorization policy:

For all patients, we perform procedures and seek diagnostic studies only when medically necessary. We treat your concerns with the most natural methods possible, and when a medication is required we will seek to use the most cost-effective option. For ILM members, we will provide 10 minutes of staff time for each prior authorization before you incur additional fees based on the required staff resources. For non-ILM patients, you will be charged for the staff resources required.

It is unfortunate that we are not able to circumvent this process. If there is a procedure, diagnostic test, or medication that is medically necessary, we will work hard for you to get what you need.