About Us

Insurance Issues

If you have medical insurance you expect it to pay for your medical expenses, under the rules of your policy.
Please read the following carefully.
The procedure for getting your insurance to pay for your care at the IBS Treatment Center may be different than at other medical facilities with which you are familiar.

CPT Codes Quick Link: CPT Codes

How it Works:

It is as simple as 1, 2, 3.

• 1. You pay the IBS Treatment Center by cash, check, Visa®, Mastercard®, or Discover®.
• 2. You submit to your insurance company the paperwork we provide.
• 3. Your insurance company pays you back in accordance with your policy.

When you are seen at the IBS Treatment Center you will pay in full at the time of service for your office visit and any testing, medications, etc. If you purchase a package of office visits and testing you will pay for the entire package. You can pay with cash, check, or with a Visa®, Mastercard®, or Discover® debit or credit card. If your insurance company or health savings plan has issued you a Visa® or Mastercard® payment card you can use that. Along with your personal billing summary and receipt you will receive a duplicate billing summary, an explanation of the codes on it, and a cover letter to your insurance company. You simply sign the letter, add your subscriber number, and mail the letter, the billing summary, and code explanation sheet to your insurance company's claims address (on the back of your insurance card). Ideally your insurance company will then send you a check reimbursing you for your expenses or the portion of your expenses covered by your insurance policy. If they are quick, your insurance check may even arrive before your credit card bill.

See below for alternatives to low deductible insurance.

After the Claim is Submitted:

Most of our patients report that they get at least some part of their charges reimbursed. Some patients have reported simply submitting their claim and getting a reimbursement check back. Unfortunately insurance companies do not always honor their promises. Some patients have had to spend significant time and effort to get fair compensation. See this page for advice from one patient who was able to eventually get thousands of dollars in reimbursement, with some effort. You may need to take some steps to remind your insurance company that you pay them monthly premiums and they promise to pay claims in a timely fashion. Sometimes claims are denied outright, or the insurance company delays the claim by asking for more information. Often the information they ask for was provided as part of the initial claim. When this happens you may choose to communicate directly with the insurance company, or file a complaint with the state insurance commissioner. The insurance company usually can be persuaded by one technique or the other to pay what they are obliged by the policy to pay. Sometimes they even completely reverse their initial denial and pay the entire claim. (see this example from Regence BlueShield or this one concerning a Boeing Employee with Regence).

A Special Note About 'Out of Network' Providers and Insurance:

The attorney general of New York State has investigated a group of health insurance companies for fraud particularly with respect to 'out of network' providers (press release). There was an article about it in the NY Times. One quote from the article is particularly interesting:

The attorney general’s investigators did their own survey and concluded that $200 is the fair market rate in New York City and Nassau County for a 15-minute consultation with a doctor for an illness of low to moderate severity. Ingenix, the investigators said, calculated the rate as $77, of which United would pay $62, leaving the patient to pay $138. UnitedHealth disputes those numbers, so the attorney general will need to offer a fuller explanation of how they were derived.

The IBS Treatment Center currently charges $199 for a 35 minute consultation with a physician (rates subject to change).

Patients are sometimes able to get their insurance companies to allow charges from the IBS Treatment Center to be paid at 'In Network' rates, as if the IBS Treatment Center was contracted. These notification letters(1) and (2) advising us of the situation came from BlueCross BlueShield of Illinois. Wouldn't it be great if they just paid for care, without all the hassles, exceptions, reversals, etc.?

To hear a great talk by the guy (T.R. Reid) who wrote the book about all the healthcare systems in the world that explains how the US system differs, check out the audio recording of his talk.

Tips:

To get the maximum reimbursement from your insurance company it may be helpful to take a few extra steps. You can establish a relationship with your insurance company and get to know a few people that are involved in claims adjusting and payment. You can also become familiar with your rights under your state's regulations.

Most states have a state insurance commission that regulates the medical insurance industry. The National Association of Insurance Commissioners (NAIC) has a page with a map that links to the web site of all the states' insurance commissions, even D.C., and Puerto Rico, (click Here). Many have a complaint form and information about the process right on their web sites.

Some patients feel it is worthwhile to get 'pre-approved'. We have not had any reports of success in getting the insurance company to promise, in writing, to pay a specific amount for a specific claim. But since insurance policies should be clear about what is covered and how much will be paid, it should be possible to get an exact commitment for a given set of services.

To try, check with your insurance company prior to setting up your appointment. Let them know you plan on being seen and provide them with the Tax ID numbers under which the IBS Treatment Center operates and the National Provider Identification (NPI) number. Those numbers are:
Tax ID Numbers
Innate Health PLLC: 20-3147684
NPI: 1659430585

You can provide them with a copy of our CPT code sheet (link here - requires Acrobat Reader available here) that explains the various charges associated with certain codes. You may not need every test or procedure, and there may be things you need that aren't on the sheet, but this should cover the majority of scenarios.

Frequently Asked Questions about Medical Insurance:

Q: Did an article in the Wall Street Journal compare health insurance to the mafia, indicating health insurance was worse?
A: Yes. The author of the article pointed out that the mafia may use force and intimidation to take a 'cut of the business' but they don't also try to increase their part of the 'cut' by harming those being 'protected' by the service. Read it for yourself at http://online.wsj.com/article/SB120813453964211685.html?mod=opinion_main_commentaries.

Q: What does it mean when a doctor says they "take insurance"?
A: Many doctors/clinics/hospitals have a contract with one or more insurance companies. Sometimes this means that they are part of 'Preferred Provider Networks". These healthcare providers receive their primary income from the insurance company and thus essentially are independent contractor employees of the insurance company. When you go to these facilities you might pay a co-pay, or you might pay nothing at the time of service. The provider sends the initial bill (minus any co-pay you paid) to the insurance company. Final responsibility for the total bill remains with you, but the insurance company will pay some part of the bill, sometimes the entire amount. The insurance company decides whether or not the charges are 'covered' and whether or not they will pay each individual charge for you. In many cases they determine ahead of time, by contract with the provider, what they will pay for and thus what services are available for a given situation. Any amount not covered by your policy is usually billed to you, often months and sometimes years after the fact. Under these contracts there are strong incentives that control how you are treated by the provider. These incentives have little to do with what is in the best interest of your health. We don't think this is the way to practice medicine.

Q: Why don't you "take insurance"?
A: Many of our patients do get their insurance to pay for at least part of their care at our clinics. The more appropriate question is "Does my medical insurance policy cover effective, successful care?" Our clinics often successfully treat patients who have been seen and have not had success with doctors working in facilities that "take insurance" (see above). Medical insurance is theoretically supposed to manage risk by using a pool of money collected from a group to pay for medical conditions that may affect any specific member of the group. That is why you pay (or your employer pays) those high premiums every month. The idea of insurance is to pool money together to manage risk. Unfortunately, the way insurance operates is more about managing costs than managing health. The insurance companies don't make more money by helping people be as healthy as possible, they make money by keeping as much of the premiums they collect as they can. Thus they have a strong incentive to deny payment and to limit claims. This is unfortunately so common that almost all states have passed legislation that guarantees patients the right to appeal denial of their claim to an independent body. Reversal of denials have been as high as 72%.REF (More information is available from the Kaiser Family Foundation www.KaiserFamilyFoundation.org ). The IBS Treatment Center is not bound by any contracts to any insurance companies. As a result we are directly responsible, both morally and financially, to you, the patient. As a result, our incentive is to make you as happy and healthy as possible. Your insurance company is both morally and financially bound to you by your insurance policy. Your insurance policy is basically a contract between you and the insurance company. So you might ask "Will my insurance company honor their policy?" and perhaps "Do I have the right insurance policy to get the health care I need?"

Q: Why do insurance companies have "Preferred Provider Networks"?
A: Insurance companies are businesses, some are technically not-for-profit, that focus on financial issues, not on your health. In order to manage their expenses, insurance companies use their control of billions of dollars, collected as insurance premiums, to place limitations on exactly what a doctor can and cannot do for a patient based on their symptoms or diagnosis. This is a major innovation of modern medical insurance in the United States. The extreme example is the HMO or "Health Maintenance Organization". These organizations control all aspects of medical services delivered to those covered by their policies. This allows the insurance company (HMO) to choose the least costly, not necessarily most effective, ways to manage health. As long as they don't violate the law they can legally provide extremely inexpensive care to patients, regardless of the health outcome. Preferred Provider Networks are similar to HMOs in that the providers are bound by contracts that limit what they will be paid for. Within the bounds of medical insurance contracts, doctors are not encouraged to seek any better forms of treatment than those allowed by the insurance company. The for-profit, publicly traded health insurance companies are legally bound to maximize shareholder profits, regardless of the effect on the health of the policy-holders insured by them. The largest of these include United Health Group, Cigna Corp., Aetna Inc., Wellpoint, Inc. and Humana, Inc.

Q: Why is treatment at the IBS Treatment Center different than what is provided by others?
A: The insurance companies evaluate various diagnoses, determine what they consider to be reasonable to address each specific diagnosis, and establish a "standard of care". In some cases this includes a standard prescription for a specific pharmaceutical. The options available to the doctor can be to prescribe the recommended drug or try to negotiate an exception, usually an extremely complex, time-consuming process. Rather than being rewarded for successfully diagnosing and treating patients, the incentive (financial) for doctors working with insurance companies is to provide the "standard of care" that the insurance company allows for a patient's stated condition. Unfortunately, this kind of care often falls short of actually curing a person of their illness. In this model the doctor is working for the insurance company, not the patient.
We think the "standard of care" for IBS is unacceptable because it fails to treat and cure patients with IBS. We have developed a thorough, successful, individualized treatment strategy that is only possible when free from the "one-size fits all" restrictions imposed by insurance companies. Each patient's history and symptoms are considered. Specific lab tests are then chosen based on the patient's individual situation. Finally a treatment plan is created that is specific to the individual's lab results and condition. We answer to no one but you! And this is what allows us to be so successful in treating IBS.

Q: What other reimbursement options are there?
A: It is becoming more common for employers to offer Health Savings Account (HSA) and/or Flexible Spending Account (FSA) benefits to employees. These programs can enable you to get reimbursed for your medical expenses. Your employer, human resources department, HSA administrator, or FSA administrator can provide more information about payment and reimbursement.

Most people have health insurance that is supposed to cover all their regular office visits as well as unexpected accidents and illnesses. They pay very high monthly premiums (or their employers do) and find that when they need a doctor the waiting list is long, the visit short, and the experience unpleasant. Others have found a better way. Use insurance for high cost, unpredictable needs and pay cash for predictable, regular expenses. One primary care practice in Seattle is providing just such a solution, just pay $50 to $80 (depending on age) per month and see the doctor as often as you need to - no co-pay, no denials. Check them out at Qliance .