Functional Medicine

Is Functional Medicine Covered by Insurance?

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Is functional medicine covered by insurance is a question we get often, and it’s a sensitive subject for many. As I do my best to explain this answer, please know that the model we’ve chosen was what we felt allowed us to provide the best individual care in a holistic functional medicine practice for each patient. As with many things in medicine, what’s covered by insurance can change, but at the present time…

 

Is functional medicine covered by insurance?

 

Chances are, if you are in a true functional medicine practice where your doctor is practicing in a functional medicine model of care and not a conventional insurance model of care, the most likely answer is no, it’s not covered by insurance.

 

What’s the difference between the two models of care?

 

Conventional insurance-based medicine is built around the concept of labeling you with a reimbursable diagnostic code (diagnosis) and then finding the medications or a procedure to match.

 

A functional medicine model of care works through the functional medicine matrix, balances imbalances, considers the connection of mind-body-spirit and often can’t label your symptoms with a single diagnostic name because body systems communicate. We remove the artificial silos of body parts into specialty areas of conventional medicine and consider you as a whole person, mind and body, with communicating body organs/systems. The core of functional medicine is finding the why, or the root cause, and simply operating in a diagnosis to medication model doesn’t fit. (You can read more about “what is functional medicine?” here.)

 

In addition, if your doctor is spending enough time with you (both in person and afterwards researching your unique case) to get to the root of your issue, using advanced testing that takes more time and knowledge to interpret, and then personalizing your treatment plan to include natural therapies, the most likely answer is no, it’s not covered by insurance.

 

Many treatments in functional medicine are considered “alternative” because they don’t involve a medication for symptoms, but rather supplement an individual’s unique needs. Functional medicine doctors understand that what works for you might not work for the other 99 people in the study, because you have a unique genome, microbiome, and lifestyle – factors that aren’t considered in mainstream medicine recommendations.

 

So true functional medicine approach doesn’t often work with insurance but, here’s

 

why that can be a good thing:

 

Insurance-free practices allows for:

 

  • Advanced care. Being “insurance-free” allows doctors to recommend the most advanced therapies and testing. One study showed that conventional doctors took an average of 17 years to change behavior, from the time of new scientific information. The insurance model keeps doctors stuck in the current “standard of care” because that is often what is reimbursed, even if that standard of care is outdated. Insurance covers what they can easily track (expense to benefit) and unfortunately one of the easiest things to track is medication. Medications are also easier to study because it’s one intervention and not a more difficult to measure multi-factorial approach of lifestyle and natural therapies. (Not to mention medication studies have more funding). Yes, medications can be life-saving and necessary and as an MD I still prescribe them, but it is only part of our treatment plan.

 

  • Personalized care. In functional medicine, we base treatments on the best possibilities for an individual with a unique genome, microbiome, and lifestyle, instead of basing our treatments simply on what the insurance company tells us they’ll pay for.

 

  • Time.  Insurance reimburses doctors’ visits that typically last about 15 minutes. We often spend over an hour with our new patients, getting a comprehensive assessment. We have to know what is going on in your life before we can improve it.

 

  • Flexibility.  There are no restrictions with where or how your care can be given – in office, home, phone, or video. We can meet patients where they are.

 

  • 1:1 personal relationship. There’s no one in between your doctor and you. It’s a true partnership. Your doctor is only working for you. She’s not caught in a triangle between you, insurance, and administration.

 

  • Transparency.  There’s no guessing game of what’s covered, surprise lab bills in the hundreds of dollars for necessary tests that you felt should be covered. We spell out lab costs, decide together which tests are important and let you know the worst case pricing if the insurance doesn’t cover. We also offer much lower, direct pay pricing on many common labs.

 

  • No barriers to seeking care and support when you need it. There are no penalties for seeing us (like co-pays). In our model, we expect to see our patients frequently so that we can help them through the healing process.

 

 

But, functional medicine is expensive, right?

 

First, we consider functional medicine an investment over an expense. Working to transform your lifestyle and health will continue to reward you over your lifetime.

 

Functional medicine is not more expensive than repeat colonoscopies, ongoing work-ups with no answers and expensive imaging, “blockbuster medications” that only increase in dose and number, or an emergency that could have been prevented.

 

We see people from all walks of life, including hard working people on a fixed budget. They are willing to invest in their health and to them, it’s more of a priority decision than a cost decision. They’d rather not wait and keep doing the same things, taking the same medications, but expecting a different result. The upfront investment they make both financially and effort-wise often completely change the course of their health over their lifetime.

 

We still absolutely encourage our patients to have insurance, especially for acute medical needs. And although we don’t work with insurance directly, there are still ways to reduce the cost of functional medicine:

 

  • Insurance can be used to lower the cost for many functional labs.

 

  • HSA/FSA dollars are often able to be used for our medical and dietician consults (check with your carrier). This can give you more control over your health care dollars. Now, as many insurance plans have higher deductibles, many employers offer HSAs as part of the health plan.

 

  • The savings we are able to pass on to patients on direct lower cost conventional labs can offset the total cost of functional care.

 

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