One of the most common questions we get when potential patients call TWIHW, “Is this covered by insurance?”. Unfortunately no, functional medicine is not covered by insurance but that doesn’t mean you cannot use your insurance with functional medicine.
Traditional insurance and what is covered, is largely based on the conventional medical model of care. Conventional medicine is oriented toward acute care, the diagnosis and treatment of trauma or illness that is of short duration and in need of urgent care, such as appendicitis or a broken leg. This means that only those tests, procedures and services commonly used in a conventional medical model (for acute and urgent care) will be covered. It is also the reason why most conventional medical doctors never order tests that we as Functional Medicine providers typically need to identify the actual cause of your health problems.
Because traditional insurance (conventional medicine) isn’t accustomed to prevention of disease or identifying the root cause of chronic health conditions, they only cover specific lab tests within very specific time frames, procedures and services that allow for a potential diagnosis. That diagnosis often leads to a prescription or medical procedure that is usually covered for urgent or acute care needs.
But if you’re interested in a Functional Medicine approach to your healthcare problems – an approach that will ask “Why do I have a particular diagnosis?”, then most of the time coverage will be limited. Depending on your insurance and out of network benefits, some patients have been able to receive credit towards their out-of-network deductible, they have also been able to use their insurance for some of the labs depending widely on type of labs ordered, and even some of the medications. When needed we will provide you with a detailed superbill that you can provide to your insurance company to seek any out-of-network benefits that they may offer to you under your plan.
The Woodlands Institute for Health and Wellness, is not contracted or affiliated with any insurance company or hospital system. Some insurance companies view Functional Medicine as being Experimental/Investigational and as such will state that your care at TWIHW is not eligible for reimbursement. It is the patients responsibility to understand your insurance benefits. Because we do not file insurance in this office, we do not have an insurance specialist to handle problems that may arise with your policy. In an effort to help mitigate costs for your wellness journey we do have a list of cash option resources for Diagnostic Imaging, Labs, and Medications.
All office visits and services are paid for at the time of your visit. We do not bill the insurance company. Dr. Mila McManus, Sandra Caldwell PA-C, and Dyvette Warren PA-C are not Medicare Providers. No claims can be made to Medicare or any other government sponsored medical plan. You will need to sign an acknowledgement agreement specific to government programs prior to your initial office visit.
Regarding Labs and Insurance:
Your lab order and diagnosis (aka ICD-10) codes are produced during your visit with your medical provider. Your provider has determined that, based on your current medical needs, the ordered labs are necessary to provide you continued treatment and care. If you choose to have your labs billed to your insurance company, the insurance company may or may not cover those lab charges. All medical diagnosis codes assigned to you at your office visit will be used on the lab order. If the insurance company deems any or all of your labs as not medically necessary, it means the labs will not be covered. There are no additional diagnosis codes that can be sent. Should this occur, and you have gone to Quest Laboratories for your blood draw, we can provide you with a quote at our contracted rates. The rates provided to our practice are significantly lower than retail. So if you receive a bill from Quest, please contact our billing office for a quote. Unfortunately, we are not able to help if you use any other lab to have blood drawn.
Regarding Medications and Insurance:
Your medical provider may issue prescriptions that they feel are medically necessary for your treatment based on your symptoms and/ or labs. Some of the medications may be compounded through a specialty pharmacy and some may be commercial products available through your regular pharmacy.
Compounded medications are sent to specialty pharmacies that produce the prescribed medication especially for you. These medications are not covered by insurance but some of the compounding pharmacies will provide you with detailed billing so that you can attempt to receive reimbursement. TWIHW recommends select compounding pharmacies that they have utilized and have had consistent high quality and effective treatment through. You are welcome to choose your own compounded pharmacy but please remember that there could be variations in the products that could result in symptoms not resolving or worsening. Here is a great article that can help you when selecting your compounding pharmacy: 5 Myths to know before choosing a compounding pharmacy.
Commercial prescriptions, available through your regular pharmacy, will be sent to any pharmacy of your choosing. Generally patients have been able to receive coverage for these medications through their insurance. However, there are many instances where the prescription is not covered or they require a prior authorization. Due to the fact that we are not contracted with any insurance company we are unable to complete prior authorizations. If your medication is denied we recommend that you check www.goodrx.com for cash pricing options. This website will provide options for various locations and pricing to help you offset the cost of your prescription. If you are still unable to obtain the prescription due to pricing please notify the office at email@example.com so that we can update your medical provider.
Regarding Diagnostic Imaging and Insurance:
Your medical provider may order diagnostic imaging that they feel is medically necessary based on your symptoms or treatment plan. Some insurance companies and/ or imaging facilities may require a pre-authorization prior to you receiving the imaging. Please note that because we are not affiliated with any insurance company or hospital system we are unable to obtain pre-authorizations. If you would like to utilize your insurance for any imaging and you have been told you need a prior authorization please contact your PCP for assistance. Alternatively, we can provide you with a list of facilities in the surrounding area that provide deeply discounted cash prices for select imaging services.
List of Local facilities with cash options:
In all cases, we appreciate and expect payment in full for our services at the time they are rendered and in return we pledge to provide you with exceptional attention and medical care as we place you on a life-long path of health and wellness.
You may use FSA and/or HSA funds for most of our products and services.