A growing number of people in the United States wish to use more natural healing methods and are seeking out alternatives to conventional allopathic medicine. Naturopathic medicine is one of the fastest growing and most beneficial of these alternatives. Although many people would like to be treated by a naturopathic doctor, they are not because they think that naturopathic medicine is not covered by their insurance. This is not always true!
Many insurance companies do cover naturopathic medicine! Those companies that say they do not naturopathic medicine, may say this because they do not know how to handle the claims or the claims agents may be unaware of the licensed naturopathic medical profession. This will change only when enough people file claims or ask for coverage.
In the state of California, naturopathic doctors are licensed to practice medicine. Therefore, unless your insurance policy specifically excludes naturopaths, by law they must cover the services. Because naturopathic doctors are usually not included on the list of covered providers, the reimbursement you will receive will usually be an “out of network” reimbursement.
To find out if your insurance company will cover your naturopathic medical services, there are a few things you can do:
1. Look at your policy.
If the “Definition of Doctor” in your policy does not specifically either exclude naturopathic doctors, or limit the definition to specific providers other than naturopaths, then you should, by law, be covered for your naturopathic services.
2. Call your insurance company.
The following are a few suggestions of what to say/ask while on the phone:
- Does my policy cover services performed by a licensed naturopathic doctor? (they will typically say no because many agents are unaware of what naturopathic medicine is)
- Does the “definition of doctor” in my policy specifically exclude naturopathic doctors? (ask them to fax/email you a copy of the definition)
- Does the definition limit services to specific health care providers? Which ones? Naturopathic doctors are primary care doctors licensed to practice medicine in my state. If necessary, I can provide you with a copy of my naturopathic doctor’s license for further documentation.
If your policy covers naturopathic medical services, simply file your claim as you would any other. Your naturopathic doctor will provide you with any necessary diagnostic codes, signatures, etc.
If your policy does not cover naturopathic medical services, you can try to modify your policy. Most insurance companies will write a plan to cover naturopathic medicine, but you must request the coverage. The more often such a request is made, the more often insurance companies will fulfill the request.
Ask your agent to add coverage for naturopathic services. There may be a small charge for this service ranging from nothing to a few cents a month.
Most insurance companies do not charge anything extra to cover naturopathic services on a group plan. Tell this to your employer, union, or human resources director, and ask that naturopathic doctors be added to your plan. If necessary, organize and educate your coworkers or human resource department on the value and benefit if naturopathic medicine. Any of the doctors here would be happy to help!
How to Appeal an Insurance Denial
If your insurance company denies coverage for a treatment recommended by a naturopathic doctor, don’t panic. There are steps you can take to appeal the decision. Talk to the insurance company representatives and request an internal appeal. If that doesn’t work, you may have the right to go over the company’s head— to an external review board.
The following pointers will help make you a better self-advocate. They will also help us help you more effectively:
1. Learn what you’re entitled to.
A treatment may be just what the doctor ordered. But if your health plan doesn’t cover you for it, it may cost you out of pocket. Look at your benefits booklet to identify what you are covered for: No plan will pay for a heated pool to treat your arthritis. It might reimburse you for an exercise program, however.
2. If you receive the notice that your naturopath is not recognized on your plan as a definition of a doctor, please file a grievance with your company.
According to California law, all providers are eligible to receive reimbursement if they provide service within the lawful scope of their license. Naturopathic medical doctors are primary care providers in the state of California. Naturopathic doctor’s scope of practice is that of a primary care doctor, and as long as the services provided to the insured patient were those using typical evaluation and management codes, distinctly separate from any alternative services your policy may or may not exclude, payment on the claim for services dated ________should not be considered an overpayment or payment in error.
3. Enlist help.
Most health plan denials don’t require a formal appeal. They may require some creativity on your part, however. If your coverage is through your employer, for instance, ask your benefits manager to call about the denial. Because that manager is paying the tab for lots of employees, that person has got clout.
4. Write the right letter.
Even the best-written, most impassioned letter will fall short if it doesn’t address the health plan’s real concern. Save yourself some time by talking first to a health plan representative. Find out exactly what needs to go into the letter—down to the exact wording, if necessary. Then draft a letter, and ask a Naturopathic doctor to review it before sending it out. We are happy to help.
5. Do your homework before filing an external appeal.
This step is rarely necessary. However, if you’ve exhausted all your internal appeal options, be prepared to take your case to an independent appeals board. (Most states have provisions for an expedited or fast-track appeal in emergencies.) Among the resources that will help you prepare are:
A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan Update.
This free guide will give you a state-by-state breakdown of external review programs, eligibility requirements, and contact information. Copies of the guide are available at either: www.kff.org/content/2003/20030123a
or www.consumersunion.org/health/hmoreview or by calling the Kaiser Foundation’s publication request line at 800-656-4533.
Patient Advocate Foundation
Located in Newport News, VA. One goal of this organization is to mediate disputes between patients and their insurers. Contact the foundation at www.patientadvocate.org or by calling 800-532-5274
Disease-related groups and associations
Groups such as the American Cancer Society, the Arthritis Foundation, the American Diabetes Association, the Epilepsy Foundation, and the Lupus Foundation of America can help. Each of these groups can lend their expertise during an external appeal.
Employer patient advocacy programs
An increasing number of employers have contracted with companies like Health Advocate (www.healthadvocate.net), based in West Conshohocken, PA, to advise and, when appropriate, go to bat for their employees. Ask if your company makes this employee benefit available.
Remember, each request to insurance companies has a cumulative effect. So, going through this process may not only benefit you, it may benefit the greater good. Naturopathic medicine ought to be covered by insurance, it would be cheaper for the insurance company to do so! In other words, it’s in their best interest to make these policy changes as well. Hopefully, with all of these suggestions, you’ll be able to make some positive changes for all.