Insurance and Payment FAQ
Do you accept insurance?
Coastal Functional Medicine has 'opted-out' of Medicare. Our office does not bill insurance. You may pay by check or credit card. Upon request, we can provide you with a copy of a superbill which you can submit to your insurance company for possible reimbursement for out-of-network care. The superbill is a detailed medical receipt that contains procedure codes, diagnosis codes, and the fees charged for your office visit. We cannot guarantee what reimbursement if any, you may receive. We do not submit claims or call insurance companies directly. This is the responsibility of the patient.
An Explanation of Our Financial Policy
Here at CFM, we are passionate about what we do, and we feel that we have a calling to provide as many people as we can with the highest quality health care possible. Just as our services are unique, our financial policies set us apart from mainstream medicine. We have prepared this handout to answer any questions you or your family members may have about the rationale for our financial policies. If, after reading this, you still have questions, feel free to speak with us.
Why We Do Not Accept Insurance Assignment
Many people who have contacted our office for our services have asked us why we do not bill insurance directly when other medical providers do. We fully understand the financial challenge this presents to some patients, and we wish there was a way to bill your insurance company. Unfortunately, at this time, there is not. Here is why:
When clinics bill health insurance companies directly, the doctors are required to become participating providers. The doctors must sign a contract that allows the insurance company to determine which services they will, and will not, provide and how much they can charge for those services. In general, insurance companies are not focused on preventative or wellness services. They are heavily invested in the conventional model of health care that too often relies on drugs and surgery. We are committed to the functional medicine model that involves understanding the origins, prevention, and treatment of complex, chronic disease.
A participating provider must agree to accept the fees the insurance company establishes, regardless of whether the fees are reasonable or applicable to that practice. In general, these established fees cover the actual cost of the briefest (and I believe the lowest quality) care.
Doctors who are participating providers are required to accept discounted fees for their services, and they cannot bill the patient for the difference between their fee and what the insurance company will pay. Therefore, the clinic must write off the difference, often as much as 50% or more of the doctor's fee for services. At the same time, the participating provider's office overhead costs have increased dramatically because of the staff, time, and equipment necessary for processing and tracking claims.
In today's healthcare environment, the actual cost for doctors to provide services continues to rise, while the percentage of reasonable fees that insurance payments cover is declining. At the same time, the profits of health insurance companies and salaries of their top executives continue to rise to record levels.
Most doctors and clinics cope with the requirements of being participating providers by keeping their office visits very brief, so that they can see more patients within a given time frame. When their clinic becomes unprofitable, it must be supported by another institution. Most primary care medical clinics are not financially self-sustaining and have had to merge with hospitals whose expensive, high-tech surgical and diagnostic procedures are priced to keep the clinics afloat financially. Ironically, some of our patients complain about their extremely brief and unsatisfactory office visit in other medical practices, while at the same time expressing frustration that we do not accept insurance. Unfortunately, we have found that we cannot be participating providers in the insurance networks and provide the time-intensive, well-researched, expert intensive care that we do.
Why We Must Charge for Your Follow-up Consultations
Some Patients have asked why we charge for follow-up consultations regarding lab results and exams as well as for telephone consultations. Dr. Fleming is not salaried like other doctors who are employed in large clinics and hospitals and whose salaries are partially subsidized by expensive diagnostic and surgical procedures and hospital fees. Dr. Fleming's pay is based solely on the time and services she provides. Like all non-salaried professionals, including lawyers and accountants, Dr. Fleming must charge for her time so she can afford to provide you with care and remain in business. In general, we charge only for our face-to-face time with you. Dr. Fleming spends considerable non-reimbursed time regarding your care, reviewing your records, developing an extensive treatment plan specific to you, and improving the quality of services.
In follow-up visits, Dr. Fleming spends significant time discussing your results with you. For example, it is relatively simple to inform a patient that her mammogram is negative, but it is entirely different to discuss the results of more complex functional evaluations and to recommend practical lifestyle and dietary strategies that may help to prevent breast cancer. Patients often complain that conventional doctors do little to nothing in the way of truly preventative medicine. We want you to understand that preventive health care takes considerable time and expertise on the part of the doctor and that someone has to pay for that time and expertise.
About the Charges for Our Services
Dr. Fleming has chosen this work because it is her passion and calling and certainly not because it is a way to make a lucrative income. In fact, most medical doctors who choose to practice functional medicine know that their income will be substantially lower than it would be if they were practicing in a more conventional manner that is fully supported by the healthcare reimbursement system.