Prolotherapy Nashville does not participate in Medicare, and Prolotherapy treatments, as a formal policy, are not covered by Medicare. Therefore, Medicare-aged patients (whether or not primary coverage is through Medicare—‘alternate’ insurance plans for medicare-aged persons, and ‘supplemental’ policies mirror Medicare policies) will need to sign a waiver indicating that they are aware that this is a ‘non-covered service’, and recognizing that payment for these services is entirely up to the individual. It is improper for a person, knowing that Medicare does not cover these services, to then attempt to bill Medicare or Medicare-related insurances for such services. This can be construed as fraudulent billing, and patients must agree to refrain from doing this.
Prolotherapy Nashville has no contractual relationship with, and does not accept assignment from, any insurance company. We are not involved in any insurance company’s determination of what they prefer to ‘reimburse’ for services. We will give you all the codes and information, on your invoice, that are necessary to file a claim with your company. Please keep YOUR copy of this document. The office keeps a record of the global charge at each enounter, but DOES NOT keep details of diagnostic coding that are provided to you at your visit! Therefore, we may be unable to provide you an accurate replacement if you lose your document. Many patients do receive some reimbursement, and occasionally full reimbursement is noted. This is highly unpredictable, even with identical claims presented to the same company. Unfortunately, our staff will not be able to contact your insurance company for the purpose of ‘trouble shooting’. If additional information is requested by your company (office notes, etc.), we will be happy to forward these documents to you and you may provide them to your company at your discretion. Insurance company ‘requirements’ change frequently. While we make efforts to ensure that codes are correct and current, we can make no representation as to how your company will respond to a claim. A determination by an insurance company as to ‘medical necessity’ or ‘reasonable and customary charges’ represents the contractual relationship between a person and their insurance company, and in no way influences the medical judgement, nor the fee structure, of Prolotherapy Nashville.
WHY DOES MY INSURANCE COMPANY OR MEDICARE NOT ‘COVER’ PROLOTHERAPY?
Some insurance companies do reimburse for some Prolotherapy treatments. Standard diagnostic and therapy codes are used, and there is reason for denial of these claims except fluctuating company policies. While insurance companies do review medical literature when contemplating ‘covering’ a procedure, as does the government, these reviews are in no way a validation, or a refutation, of the merit of any treatment. ‘Coverage’ for these entities is ultimately a ‘business decision’, not a ‘medical decision’. There has always been, and continues to be, good evidence in the scientific literature. Therefore, persistence in pursuing and following-up on your claims, and challenging denial of payment, may be advantageous to you. You will likely encounter the same ‘roadblocks’ to reimbursement that physicians’ offices have been confronted with since insurance began covering physician charges around 1990. Prior to this time, patients simply paid for their visits, treatments, and operations out of pocket, so paying for physician services is not a ‘new’ idea. Due to the unpredictable nature of commercial insurance reimbursement, we cannot rely on ‘insurance payments’ to fund the function of our office. If you require insurance reimbursement in order to receive this treatment, this treatment option may not be for you. Even if some reimbursement occurs with one claim, there is no assurance that future identical claims will be handled in the same manner. Insurance companies can also ‘change their mind’, and ‘require that your return reimbursement’ up to 18 months after they send you a check. These companies are not there to ‘provide healthcare’ for you. They are there to collect premiums, and then to pay out as little money as possible to providers, and to you. You need to be well aware of these realities as you consider this treatment. Medicare, based on the above described ‘research’ that was poorly designed and performed, has classified Prolotherapy as ‘investigational’, and, as a formal policy, does not ‘cover’ Prolotherapy or any associated services.
WHY DOES PROLOTHERAPY NASHVILLE NOT FILE MY INSURANCE CLAIMS?
Medicare does not cover any Prolotherapy or related services as a policy. Commercial insurance covers erratically and incompletely. But the costs of the computer systems, the programs that interface with each company, and their frequent upgrades and ‘new’ required programs, and the personnel costs to run, and to troubleshoot, these systems represent tens of thousands of dollars per month for a medical office. In the interest of keeping the cost of Prolotherapy affordable to most people, whether they have, or do not have, the possibility of reimbursement, we have chosen to not incur these costs, and to keep our prices as low as possible. While a given treatment in our office may be ‘more than’ a treatment by another Prolotherapist (though often it is not), we typically do larger and more thorough treatments at each session, and resolve problems for patients more quickly, than most other practitioners. We also strive to use the most cost-effective effective options for our patients. Therefore, our overall treatment costs to completely remedy a particular problem are probably among the lowest in the country. Our success rate is quite high, and our ‘failure rate’ is lower than any rate I have seen in print, or heard of in discussions with my colleagues. The way I see it, my job is to fix your body, while guarding your wallet to the extent possible.