Fall 2013 Newsletter
Fall has officially arrived and now is a great time to balance, prepare and stay healthy for the seasonal shift. In this issue we offer a few classes at the clinic, some information on annual physical exams, a thought provoking article on health insurance coverage and 5 tips on packing a healthy lunch. Keep in mind we also update our facebook page and are about to launch blog posts for more free tips, recipes and community information that we hope you will find useful to keep yourselves and your families flourishing.
Table of Contents
Events at Mississippi Health Center:
- Mindfulness Workshop for Kids
- Colds and Flus from a Chinese Medicine Perspective
- Register for a class
- Let’s get Physicals! By Justin Ilsley ND, LAc
- Insurance policy reimbursements for acupuncture and naturopathic medicine: the wide maze insanity. By Beth Yohalem-Ilsley, LAc
- Lunch Tips
Mindfulness Workshop for Kids
October 11th (PPS in service day), 10-11:30am
Ages 7-12, $15/student
Instructor: Allyson Copacino of Move Yoga studio (www.moveyogastudio.com).
The lazy days of summer are gone, Fall is in the air, and school is back in session. The “back to school transition” can create anxiety, stress and sleeplessness for students and their families. Register your child for our Mindfulness Workshop, and together we’ll explore basic calming yoga poses, breathing techniques and relaxation strategies that will help your child adjust to the transition, laying the foundation for a positive school year ahead. We’ll have fun, connect with others and learn some tools to take off the yoga mat and into the world!
Colds and flus from a Chinese medicine perspective
Thursday, November 7th, 7-8:30pm
Adults only, $5-$15/person sliding scale (proceeds will be donated to Baby Blues Connection)
Instructor: Beth Yohalem-Ilsley, LAc
Get ready for flu season for you, for your child! Learn how different pathogens affect the body from a Chinese medicine perspective and when to take which herbal formulas. All participants will receive 50% off class specific tinctures at the time of the class (limitations apply).
- Register for the Mindfulness workshop on Move Yoga website at www.moveyogastudio.com
- You can register for the Colds and Flus class at MHC by calling us at 503-282-5358, emailing us at firstname.lastname@example.org or replying to the event on facebook.
Let’s Get Physicals!
By Justin Ilsley ND, LAc
There have been many conflicting messages in the media regarding what types of testing are still appropriate during routine male or female physicals. Should women get regular mammograms even if they have no family history of breast cancer? Should men have prostate specific antigen (PSA) testing to detect prostate cancer?- ever?!
These two topics in particular have been hotly debated as integral to preventative care on the one side and unnecessary or even dangerously misleading on the other. In the case of PSA testing for instance, 70% of men will have some degree of benign prostatic hypertrophy (BPH) in their sixth decade. PSA levels, which reflect inflammation in the prostate, will rise in men with BPH as well as more serious pathology such as prostate cancer. So why would you test for PSA levels if they are increasing in nearly every male and potentiate the fear of having cancer and unnecessary biopsy? In my opinion it is still quite helpful if my patients have several PSA values to compare over time. For instance, if there is a consistent trend of increase that occurs from a value of 5 to a 6 in one year, but then it doubles the following year to a value of 12, then I want to investigate what is causing the sudden inflammation.
Because prostate cancer is typically slow growing and prostatic surgery has frequent complication such as potential incontinence, some believe that the testing and treatment are possibly worse than having the cancer diagnosis itself. I have not found this to be the case. It is important to recognize that some cancers are not slow growing and that there are alternative treatments available besides surgery. I prefer that my patients have awareness of their health status and have multiple options to choose their course of action wisely.
The standard annual physical should evaluate height, weight, and blood pressure. For men, the physical should include a digital rectal exam as well as a PSA every other year after the age of 45 and annually if moderate PSA levels (2.5 ng/ml) or higher are found. For women the annual physical should also include breast and gyn exams starting at age 21. Should women get annual PAPs or mammograms? Cervical cancer screening via PAP smear is now recommended every 3 years from age 21 to 30, and PAPs with HPV testing every 5 years from age 30 to 65 by the American Cancer Society and the US Preventive Services Task Force. More frequent testing is indicated if there is a history of cancer or pre-malignancy of the cervix. The new recommendations for mammograms by The US Preventive Services are every other year starting at age 50 and earlier if there is a family history of breast cancer or if you are a carrier of breast cancer (BRCA) genes. The American Cancer Society however, has not yet changed their recommendation of annual mammograms after the age of 40. There is some concern how these new guidelines will affect insurance coverage if the tests are done more frequently or at an earlier age than recommended. This debate by the medical associations is too new and unresolved to make any sweeping policy changes. However, it is being predicted that Medicare and most private insurers will follow the Preventive Services recommendations for reimbursement. Whether or not women do have a PAP or mammogram they should not skip their annual wellness checks!
Cholesterol is no longer recommended annually if you have a history of normal results. The new standard set by the US Preventative Services Task Force is cholesterol testing every 5 years.
Colonoscopy, to rule out colon cancer, is now recommended every 10 years for those older than 50. Alternative screenings can be used instead such as barium enema, or flexible sigmoidoscopy every 5 years after age 50. (US Preventive Services Task Force 2013).
If you have not had a wellness check in quite some time, or ever, please come in to see us! And If you do not already do them, I am a big supporter of self examinations. Self digital prostate exams (men) and self breast exams (women) are important tools to track your own health. Please ask me about it!
Insurance policy reimbursements for acupuncture and naturopathic medicine: the wide maze of insanity
By Beth Yohalem-Ilsley, LAc
So you’ve got health insurance. And you have acupuncture and naturopathic medicine coverage. Cool. So…how much will you owe for your visits? Well…no one really knows until the Explanation of Benefits (EOB) arrives for each visit. What?!!! This article is an attempt to lay out, in one place, the very non- intuitive insurance process, from the provider perspective, and how it affects both members and providers.
Here is some terminology pertaining to your insurance subscriber benefits that may assist comprehension of this topic. Most plans have one or more of the following costs associated with coverage. These are determined by your insurance company and what plan you have with them. A Co-Insurance covers a specific percentage of the cost of a visit. This can vary each visit depending on the procedures performed. For example, if you have a 30% co-insurance for manual therapy which is billed at $30, your responsibility would be $10. A Co-Pay is a set amount of money that you owe at the time of service. It will not vary per visit. You may have a co-pay for acupuncture, and another co-pay for naturopathic medicine if your treatment is through a dually licensed provider. Occasionally you will have both a co-insurance for particular modalities and a co-pay for the visit (pretty sneaky, huh?). A year max refers to the maximum amount of money your insurance will pay per year (for example, all services are covered up to $500 per calendar year). A visit number max refers to the maximum number of visits (rather than dollar amount) your insurance agreement will pay for per year. A deductible is a set amount, according to your insurance agreement, that you will need to pay out of pocket before your benefits will cover any services. These nuances determine, in part, what your final bill will look like.
The billing process has a few more additional layers to go through in order to be finished with each claim (a claim is what a submission to the insurance company for each visit is called). Every claim needs to have both ICD codes (ICD stands for International Classification of Diseases) and CPT codes (CPT stands for Current Procedural Terminology). ICD codes are the diagnosis codes, why you came in (ex: headache or knee pain). CPT codes are procedural codes used during treatment (ex: acupuncture needling, hot pack, manual therapy). Both sets of codes are based in conventional medicine. Therefore most ICD codes relate to a body part or system (rather than an emotion or a wellness tactic) and most CPT codes do not include herbal therapy, moxa, energy medicine or other uniquely alternative medicine techniques. Those techniques usually are bundled into the office visit or manual therapy codes.
Most of this is fairly straight-forward. However, it gets interesting when you make a comparison of what ICD and CPT codes are permissable within each insurance plan. Many times it is not possible to determine these ahead of time since it is unlikely either the clinic or the patient would know what exclusions to ask for when signing up for the plan initially or calling about benefits before coming in for treatment. Insurance companies will cite research statistics as a rationale for what they cover and do not cover. However, making sense of these clusters of data from a human experience produces…well…. some serious head scratching. Some poignant examples follow.
Recent policy updates from Aetna[i], ODS[ii] and Cigna[iii] outlined which medical conditions they would and would not reimburse for treatment by an acupuncturist. An example from their list states that acupuncture for chronic back pain is deemed medically necessary while acupuncture for acute back pain is considered experimental and therefore not eligible for reimbursement to the provider. What this means is that if you have a newly injured back and are experiencing pain, Aetna, ODS and Cigna will not cover your acupuncture treatments. Once your back pain has been there for 3 months, they will reimburse acupuncture treatments for back pain treatments so long as there is notable improvement after 4 weeks[iv].
On the procedural end of biling, there is quite a spectrum of inconsistency. In the state of Oregon an acupuncturist’s licensing is governed by the Oregon Medical Board (which also governs MDs) and has defined the scope of practice as the following:
An acupuncturist provides health care using acupuncture and other forms of traditional Oriental Medicine. Acupuncture treats neurological, organic or functional disorders by stimulation of specific points on the surface of the body by insertion of needles. Under Oregon law, the practice of acupuncture also includes traditional and modern techniques of oriental diagnosis and evaluation; Oriental massage, exercise and related therapeutic methods; use of Oriental herbs, vitamins, minerals, and dietary advice. [v]
This definition creates some confusion with the word “acupuncture”. According to this definition, acupuncture is an umbrella term for many therapeutic methods. It is also a technique specific to the use of needle insertion along meridians. Insurance companies vary in how they reimburse for treatment by an acupuncturist. For example, Complementary Health Plans is the company who is in charge of Kaiser Permanente alternative medicine riders, meaning that with this plan you have access to alternative medicine without a referral. They will reimburse for an initial office visit. They will not reimburse for another office visit until a minimum of 6 weeks later, and then it will only be once more for the entire year of coverage, even when there are new complaints. They will only reimburse for acupuncture as a technique and will not reimburse for other procedural codes[vi]. On the other hand, Kaiser Permanente without CHP has, embedded in their regular plans, coverage for acupuncture or naturopathic medicine with a referral from one of their nurses or doctors. In this circumstance they reimburse for most procedures within the scope of practice of an acupuncturist or naturopath.
Other insurance companies vary in their coverage. Blue Cross Blue Shield will reimburse for a variety of office visits, oriental massage (manual therapy), infrared heat therapy and exercise instruction. United Healthcare does not reimburse for first office visits but they will reimburse for follow up visits[vii]. Nobody reimburses for vitamins, minerals or herbs even when they are precribed and provided by the licensed acupuncturist or naturopath.
There are new insurance plans emerging such as the Oregon Health Cooperative (www.ohcoop.org) that look quite promising. And with Obamacare about to take effect on 01/14/2014 there may be some coverage changes though we do not yet know what they will be. The intention of this article is to begin sorting through the irregularities of health insurance coverage and illuminate how it affects you, the patient/consumer, and us, the practitioners. There are no federal or state regulations regarding coverage of acupuncture or naturopathic medicine though it is clear that demand for these services is increasing and more insurance companies are including some level of coverage. My hope is that there will someday be acknowledgement that all healthcare modalities are created equal and discrimination of “alternative” modality coverage will come to an end. Imagine equal coverage for herbs and pharmaceuticals, acupuncture and surgery, manual therapies and cortisone injections.
Our website offers a guide to use when you call and check your insurance benefits. You can access this guide here: https://www.mississippihealthcenter.com/forms_pdf/check_insurance_benefits.pdf Additionally, our front desk staff is happy to call your insurance company on your behalf and check on your insurance benefits.
We welcome your comments.
1. Keep it simple. Pack one protein, one fruit, and one vegetable. And, bring a water bottle rather than juice boxes. (Leftovers never seem to win at school, but they are great for the parents!)
2. Choose nutrient dense foods, so even if the kiddos are doing more socializing than eating what they do get is enough to get them through the afternoon. A good rule is the darker or brighter the color, the more nutrients that are present. (Think of deep pink vs pale salmon, beets, kale, and squash.)
3. Be adventurous. Give your kids the guidelines of one fruit, one veggie and one protein, let them shop at the store or farmer’s markets with you. They might just choose a fruit or vegetable that you normally wouldn’t, and love it. For a protein, try jerky! You can make your own, or find a quality brand. Beef, turkey and salmon are all popular and delicious.
4. Especially for the younger ones, add some emotional nourishment. Write a short simple note, draw them picture, and add a flower or special rock. Make it a surprise and let them know you’re thinking of them during their day!
5. Finally, make up a calendar/schedule of lunches you will pack for the week. Do this with your kiddo and make it a lesson in healthy eating. Bonus, this will also encourage them to start packing their own lunch!
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