Insurance tip for integrative medicine doctors

Medical doctors practicing integrative medicine (incorporating complementary and alternative medical therapies into conventional care) face a number of insurance-related issues.

First and foremost is professional liability (malpractice) insurance coverage.

Does their malpractice carrier cover the specific holistic or CAM therapies the physician practices? Are these complementary care therapies somehow excluded?

The physician needs to inquire by phone or email, and get confirmation in writing. Consider paying for a separate rider for specific insurance coverage as necessary.

If the physician is practicing within an integrative care center or medical spa, does the professional liabilty coverage extend to vicarious liability, and/or shared malpractice liability, in case an injured patient decides to sue up and down the chain of providers?

Next is the question of how to handle Medicare patients. Even in an all-cash practice, a physician who is participating in Medicare will be bound by its rules (and reimbursement schedules) unless he or she takes a number of specific steps, including for example, those required to opt out.

Beware of hidden pitfalls, such as criminal liability for medical fraud, which can ensue from mistakes in billing and coding, including such errors as bundling charges and miscoding. Sometimes the kind of lengthy office visit that is used for an integrative medicine consult will not fit the typical E&M code.

Last on this post, consider whether any other participating agreements with insurance companies or HMOs might interfere with plans to devote, say, a day a week to a CAM-specific, integrative medicine practice.

Among other services, our law offices will draft a nonpar agreement, in which the physician notifies his or her insurance carrier that the physician will be opening an integrative medicine practice, and that this practice is outside of the participating agreement with the insurance company. The carrier then has 30 days to object and if no objection is received, is presumed to acquiesce to the arrangement. The intent of such a letter is to free the medical doctor from the tethers of the participating agreement that might otherwise restrict the MD from providing complementary care services or that might subject such services to the strictures of the participation agreement.

We will simultaneously draft a consent form that informs patients at the time of making the appointment that, should they be a subscriber to an insurance plan such as the one referenced in the Participating Agreement, they are patients of the integrative medicine center; that the Participant Agreement does not apply to the physician's services at the Center; and that plan benefits available for services to participating providers will not be available when patients see the MD at the Center.

While there are no ironclad guarantees when health care providers cross disciplinary boundaries or utilize emerging standards of care, or even when they integrate CAM therapies in a clinically responsible fashion, clarifying some of the legal rules and planning and documenting accordingly can help both medical and non-medical practitioners avoid some of the pitfalls, and learn to navigate with greater legal safety.