Insurance

One of Our Key Differences: Insurance

At Virginia Pain Specialists, it is all about You, the Patient.

Short Version

• VPS does not accept your health insurance as payment
  (one exception: Virginia Workman's Comp Insurance).
• Payment for all services at VPS is due when service is provided.
• We DO provide every patient with the documentation required by health insurance providers that contains all of the pertinent codes and information to fulfill their requirements for your reimbursement by them.

Long Version

Ours is a practice focused on helping people with chronic pain, and making the treatment of our patients — you — our only concern. One of the emergent impacts of insurance in health care is that the insurance provider ultimately controls the treatment of the patient by allowing or denying various medically valid and diagnostically appropriate treatments. The insurance company becomes an intrusive and inhibitory presence in the collaboration between patient and physician. The primary concern of the insurance company is reducing short-term costs to the insurance company to insure the company's profitability. The insurance industry does not have the long term health of the patient as a bottom line concern, since it is most likely that by the time a long term medical issue arises, the patient will have a different insurance carrier.

Our philosophy is that physicians must get out of the business of being in the middle between health insurance companies and our patients. Our relationship is with you the patient. Our concern is with the patient. Our education, experience, and expertise is in medicine. Where we must run the business side of our healthcare practice, insurance companies have compelled physicians to become gamblers, hoping that after care is provided to the patient, that the insurance company will cover the cost of the treatment. Insurance companies often don't pay physicians for medically appropriate treatment or pay only a trivial portion, in part, because physicians aren't their clients — physicians are frequently treated as adversaries or worse. In fact, it is common that a patient that directly submits a claim to their insurance provider for treatment will be reimbursed at a higher level than had the same information been submitted by their physician. It's not rational, but it is true. If you are interested, below, you may read more about the "why" of our approach.

However, as your physician, we are interested in helping our patients receive effective support for working with their health insurance provider. We understand that you don't need unnecessary burdens of worry on top of the pain you must deal with. To help you, we provide every patient with a "superbill" that contains all of the pertinent codes for their treatment. These codes include the "ICD-9" numbers and the "CPT" codes. The ICD-9 numbers identify the medical issue. The CPT codes are the numbers that identify the type of service performed to treat that diagnosis. In addition, we provide you with a copy of the "encounter," meaning our medical notes for each visit. The superbill and the visit note are what the patient submits to their insurance company for reimbursement, just as any physician would. As mentioned above, many patients actually receive a higher level of reimbursement from the insurer than had the physician had submitted the same documentation.

Recap: VPS Doesn't Bill Your Insurance Company

So to recap: one of our differences is that VPS does not act as a middleman between you and your health insurance provider. Payment for all services at Virginia Pain Specialists, Inc., is due at the time that service is provided. It is the sole responsibility of our patient to work with their health insurance provider and submit the VPS-provided standard medical information to their insurer for reimbursement and to contact their insurance company to determine their plan’s reimbursement for "out of network" medical care. We ended insurance participation as of January 1, 2010. In the intervening time, the practice has continued and that fact is a testament to the value our patient’s place in our the level of personal care they receive at VPS. Come and try us!

Why Doesn't VPS Accept Insurance?

Why has Virginia Pain Specialists, Inc., opted out of insurance participation?  The field of pain management is held in low regard by the insurance industry, in large part because it can't be quantified on a test, standardized, analyzed by statisticians to ensure their profitability, and therefore packaged into a nice neat bundle. The insurance industry routinely relies upon third party "utilization review (UR)" companies to review medical treatment. One of the primary reasons for health insurance using third party companies to review claims for approval or denial is that having a third party deny patient claims provides an aura of objectivity to the process. However, the UR field is a highly competitive one, and to keep the insurance company as a client, the review firm must show a financial advantage to the insurance company or else the latter will simply use another UR company. Ultimately, the point of the process is to have a means of denying coverage to hold costs down and enhance profitability.

As a result of UR companies, and after the physician has treated the patient, the UR company often determines that the treatment is not medically necessary. This poses a significant problem, as you might imagine, because pain management is a field that depends upon costly equipment — yet insurance coverage is limited. Insurance plans routinely discount the value of pain services including all injection therapies. This is inhibitory to both the patient seeking relief and the physician who is trying to provide that relief through effective, professional healthcare.

We are in an era when insurers have been cutting reimbursement and many standard tools for pain care have been targeted and deemed to be "elective." As someone with pain issues, you must find that at least interesting if not alarming. In addition, insurers have been implementing policies denying the benefit of certain well-established, proven pain mitigation procedures. Perhaps the most notable example is Tricare's (a large insurance company) recent determination of the "lack of proven benefit" to radio frequency ablation in the face of long-term proof of its effectiveness. The validation of the effectiveness, and of the profit-orientation of Tricare, is the fact that Tricare reversed its policy to once again cover the procedure — but not before inflicting considerable financial harm upon both suffering patients and the small medical practices trying to treat them effectively. Ironically, radio frequency ablation is one of the best documented interventions for chronic neck and back pain.

As mentioned above, payment for all services at Virginia Pain Specialists, Inc., is due at the time that service is provided.  We ended insurance participation as of January 1, 2010. In the intervening time, the practice has continued and that fact is a testament to the value patient’s place in our services. Come and try us!

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