Does my health insurance cover Functional Medicine?

That’s a great question.  In fact, that’s one of the first and most common questions people ask.  This is understandable; after all, chances are you’re paying good money for your premiums, not to mention deductibles and co-pays.  Your employer has no doubt touted the benefits of each plan, which seems generous at the time.

So where does Functional Medicine fit in?  The short answer is, I recommend that you first carefully review your policy, checking for any reference to “preventive” services, or possibly “nutritional counseling”.  When in doubt, it’s best call your insurance company directly and ask them if any of these types of service are covered under your plan.

To understand the long answer, we must first make an introductory foray into the world of so-called “health” insurance.  The first thing that you should know about health insurance is that the term is a misnomer; your health insurance company (be it Blue Cross Blue Shield, Aetna, Cigna, Humana, or worse, United Healthcare) has not made your health their top priority.  How can this be?

Well, let’s do a little research (I love research).  Quick Google searches show that the first Blue Cross plan was introduced in 1939.  Humana was founded in 1961.  United Healthcare is the new kid on the block, formed in 1977.  And the elder of the insurance companies?  Aetna has been around since 1853.

Since insurance companies are private corporations, this may go without saying, but it’s worth highlighting here: in order to survive, health insurance companies must turn a profit.  This is true of any company, family/household, or individual.  You must make more than you spend.  By definition, this means that they must take in (revenue) more than they pay out (expenses).  This means that their customers (that’s you) must pay more in premiums (as well as deductibles and co-pays) than they pay back out on your behalf (in the form of benefits, or covered services).

Functional Medicine itself requires the doctor to spend an enormous amount of energy behind the scenes between your appointments.  This time spent on your behalf includes deeply interpreting lab results and putting them together, attempting to find the underlying common cause or causes of the problem.  This may also take research and review of the newest published studies as they come hot off the presses.  No other healthcare discipline goes this far or invests this amount of time on each patient.

Since these doctors only have so many hours in a day, they’d rather devote that time to your case, (researching and reviewing your case, preparing information and treatment plans, and answering your questions), than wrangling with insurance bureaucrats, none of whom have any medical training themselves and thus lack the understanding that Functional Medicine doctors have.  Most Functional Medicine doctors would love to provide the convenience and assistance of filing insurance for their patients, but with the time and energy constraints, they find that they can’t do both well.  The bad news is, they don’t file your insurance for you and they furnish you with the receipt to submit instead.  The good news, though, is the most important: they’re not bound by their arbitrary rules, and their time can be spent where it counts–devoted to YOU.

So, about that receipt I just mentioned… Yes, most Functional Medicine doctors will provide a descriptive receipt upon request.  Depending on your insurance company, they may accept that receipt and perhaps reimburse you for part of the out-of-pocket investment you made.  I can never guarantee this, as insurance companies are like water, always changing and tough to get a firm grasp of.  Sometimes they will want codes, and this is where things get sticky…

The codes the insurance company likes to have essentially reduce you to a Dewey Decimal-like system of numbers.  Every established disease (official diagnosis) has a 4- or 5-digit number, in the form of “123.45”.  Each recognized type of treatment has a 5-digit code, too, in the form of 12345.  Although the two numbering systems are different, each recognized disease corresponds with its appropriate avenues of treatment, and vice versa.

So what’s the problem?  The difficulty arises in that these coding systems are old and outdated.  They fail to consider dysfunction (i.e. breakdowns in healthy functions or processes, the earliest signs of disease) and they also usually neglect to include contemporary health issues.  In other words, there is a language barrier between Functional Medicine and health insurance, especially considering that health insurance is actually structured around–and oriented toward–conventional medicine, which intervenes only when the dysfunction has advanced for years to decades, resulting in a blatantly recognizable, established disease condition.

The common scenario is this: you start to feel that something’s not quite right.  You visit your conventional/regular doctor, who runs the blood tests and, after scanning them quickly, says “everything is normal”.  You know that it’s not, but now they’re hinting that it’s all in your head.  Meanwhile, your health does slide further and further away from healthy ranges, toward the outlying borders of “normal” and eventually it does cross into “abnormal” territory.  This may be years later, and by then it may or may not be too late to effectively use natural methods.  But the insurance company now has a number it can assign you, a little numeric box it can neatly put you into.  They’re happy, they’ve been satisfied.  But what about you?

That’s where Functional Medicine comes in, and hopefully you’ll be able to see a Functionally-oriented doctor before you reach the disease point.  With any luck, your insurance company will cover at least part of the tab.  If they do, look at it as a secondary bonus, and if they don’t, simply consider it part of the cost of living.  After all, when owning a vehicle, we understand that if we don’t invest in maintenance, the car breaks down and stops working.  We must pay for regular oil changes, state-mandated vehicle inspections, license plate tags/stickers, brake pads (which are actually designed to wear out!), tires, and many more.  Why give your body any less?  Make your health your top priority, even if it’s not your insurance company’s.  Why?  Because you only have one body, and it only treats you as well as you have treated it.  We’re a product of the decisions we have made every day.  Up until now, people have relied on their insurance coverage for any kind of medical care.  But if we want a different result, we may have to consider a different approach…whether an out-of-touch insurance company thinks it’s medically necessary or not 🙂

How Functional Medicine works – the nuts & bolts

Practiced properly, true Functional Medicine orders a LOT of diagnostic testing because each test gives another piece of information, much like putting together a puzzle.  Basic testing only gives you part of the puzzle picture; you’re never really sure what the rest is supposed to say, and you’re forced to guess.  I don’t like putting my patients’ health at that kind of risk; it’s too important.  So the testing is non-negotiable – and why wouldn’t it be?  The human body is quite complex and there’s a lot to evaluate.

Actually, a good evaluation starts before testing is ordered:

• Lifestyle habits
• Dietary analysis
• Trauma and illness history
• Thorough symptom and metabolic questionnaires
• Complete medical history
• Vaccination schedule
• Medication and supplement regimen
• Cognitive evaluation
• Motivation assessment

An important concept in Functional Medicine is that the testing conventional doctors order is not nearly enough.  It barely scratches the surface, because the current healthcare system is driven by insurance companies who do not see the merit in prevention; they are in the business of screening for advanced, established disease and then patching the symptoms with medication when they get further out of hand.

Once we uncover and identify dysfunctions, the doctor takes a secondary, supportive role in the patient’s care as the spotlight begins to shine on patient him- or herself.  The patient’s participation and initiative become crucial for a successful outcome.  He or she may be asked/required to do any of the following:

• Dietary changes – short-term, long-term, or permanent
• Specific supplementation – short-term, long-term, or lifelong
• Specific exercises – these can include eye movements, walking, stretches, arm circles, strength training, interval training, or yoga positions
• Homecare instructions – these can include doing math or art, reading, prayer or meditation, or utilizing the senses such as listening to music or smelling various scents
• Other modalities and specialties – acupuncture, massage therapy, aromatherapy, talk therapy, thermography, colon hydrotherapy, homeopathy, physical therapy, brain-based therapy, conventional medical intervention, and more
• Other lifestyle modifications – TV or computer limitations, activity modification, sleep-wake schedules, work environment, and others

It’s a challenge, and each person must decide for themselves whether or not they’re ready to take the plunge.  Commitment is key.  Motivation is key.  The effort is worth it; one of these days I’ll share some of my patients’ success stories–real cases (while protecting privacy), to demonstrate the power and miraculous relief that Functional Medicine can bring when conventional medicine, traditional alternative medicine, and self-treatment via the web have ALL failed.  It’s truly amazing!