3 Procedures Insurance Companies Often Won’t Cover and Why They Should

Healthcare is a trillion dollar industry in the United States. And with healthcare mandates still in place, that number will continue to grow. Some people balk at that figure and complain that insurance companies care more about financial consequences than the health or science behind submitted claims. But that’s expected–insurance companies aren’t nonprofit organizations. It’s their job to make a profit.


Historically, this need to make a profit has dictated the insurance company’s approval or denial of potential procedures for patients. But is it always good business to deny healthcare coverage for some of the conditions that are excluded? Here are three procedures insurance companies won’t usually cover, and why they should:


1. Stem cell therapy.

Stem cell therapy is one of the most promising treatments for countless disorders: autism, aging, Alzheimer’s disease, autoimmune diseases, traumatic brain injuries, back pain, arthritis, COPD, diabetes, lupus, Lyme disease, MS, neuropathy, Parkinson’s disease, RSD, strokes, ED, hair loss, joint problems, heart failure, kidney failure, liver disease, spinal cord injuries, etc.


In the past, stem cell therapy was wrought with a lot of controversy surrounding the use of fetal tissue, but now, therapies are performed using the patient’s own stem cells derived from adipose (fat) tissue and bone marrow. The results are phenomenal; major improvements in conditions and often reversal of diseases. So why isn’t everyone clamoring to a stem cell treatment center for a consultation with doctors concerning treatment options? The answer lies in the failure of insurance companies to cover the procedures unless they are piggybacked with certain surgeries or trial studies.


Luckily, the future looks promising for greater acceptance from insurance companies. Covering stem cell treatments actually makes good business sense since the costs of stem cell treatments are often less than a patient’s financial responsibility after traditional surgery (something most patients don’t even realize!), substantially lowering any payout from an insurance company if treatments were covered; in addition, as individuals with chronic conditions improve, less visits to doctors mean less insurance payouts. The bottom line is more money for insurance companies if patients can get insurance coverage for their stem cell treatments.


2. Weight loss surgeries.

There is an obesity epidemic. The number of obese and overweight individuals in the US is staggering: almost 40% of the adults in the United States are obese according to a 2015-2016 study by the CDC. And with obesity, there is a surge of obesity-related health problems including type 2 diabetes, high blood pressure, joint problems, depression, heart disease, strokes, certain types of cancers, etc.


It’s estimated that the costs of treating obesity-related conditions is close to $200 billion dollars each year in the United States. Weight loss surgery has been found to reduce the healthcare cost of these individuals. Unfortunately,  although more large insurance companies are covering weight loss surgeries, they are limiting the types of bariatric surgeries patients can elect to have; limiting who can have the surgery; and requiring companies to pay additional money for weight loss riders, consequently cutting out most employees who work for small businesses and can’t afford the rider.


In addition, some states have laws requiring insurance companies to cover weight loss surgery–but only if a patient meets the health criteria (at least 40% BMI or 35% BMI with certain health conditions, and unsuccessful weight loss attempts). And often when they “cover” the surgery, they often don’t cover the entire procedure. That leaves a huge number of patients paying a large percentage, if not all, of the costs of their surgery out of their own pocket or deciding not to get a surgery that could actually cure or reverse many of their severe health issues.


If insurance companies would expand their coverage to include the best weight loss surgery for each individual patient’s needs, open coverage to all obese individuals healthy enough to have it, do away with bariatric surgery riders, and cover the entire procedure and not just a portion of the bill, their profits could actually go up as treatments for obesity-related conditions go down.


3. Fertility treatments

Being infertile may not be life threatening, but it is devastating. Sadly, over 12% of all women have problems getting pregnant or staying pregnant. For those couples hoping and dreaming for a baby, not being able to conceive or maintain a pregnancy feels almost worse than death. Many would trade their infertility for any other disability if it meant they could have a child.


The fact is, many of these couples could actually have a child if they could just afford fertility treatments. Unfortunately, very few insurance companies have infertility benefits, and the costs of receiving treatments (often tens of thousands of dollars) is more than a lot of individuals can afford out of pocket. So couples who do scrimp and save or take out huge loans to pay for fertility treatments themselves often make costly, life-risking decisions to go against the suggested one embryo transfer with IVF and, instead, transfer multiple embryos at once. They may only be able to afford one round of treatments, and they want to up their chances of bringing home a baby or two in the end.


This choice, however, often results in high risk, multiple-birth pregnancies and a higher risk of life-long health complications for mothers and children and higher long-term healthcare costs for insurance companies. Insurance companies would be financially wise to start covering infertility treatments. A study out of Alberta, Canada, shows how fully-funded IVF treatments improve health outcomes and can save the healthcare system millions of dollars over a five year time period: $29 million reduction in prenatal, delivery, and neonatal costs; and a reduction of $156 million in long-term disability costs. Quebec and several Scandinavian countries already successfully fund fertility treatments–US insurance companies should as well.


There are sound financial reasons why insurance companies should be more willing to cover stem cell treatments, weight loss surgeries, and fertility treatments. In the long run, allowing more individuals to receive these life-changing treatments will result in lower insurance payouts down the road. Insurance companies are slowly beginning to cover more individuals who need these treatments, but they still have a long way to go.

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