Insurance Reimbursement: Easy Money. Part 3

The past few years have brought many changes in the healthcare industry regarding insurance reimbursement. The Budget Reconciliation Act (BRA) of 1997, which took effect on January 1, 1999, set new limits on healthcare visits and reimbursement for healthcare services for Medicare and Medicaid patients. Managed care (HMO and PPO insurance companies) has capped reimbursement with capitation plans. Workers’ comp and PIP insurance plans are reducing reimbursement benefits because of pressure from the business community. In short, hospitals, physicians, physical therapists and chiropractors are cutting patient visits and capping reimbursements to keep healthcare costs under control. The attitude in the insurance industry is to cut and to limit reimbursement. So, based on the current state of the healthcare industry, the position of insurance companies on reimbursement and the lack of credibility for the health club industry, it’s unlikely that fitness professionals will receive insurance reimbursements in the near future.

There are, however, some scattered success stories of reimbursement for health clubs and personal trainers. Unfortunately, most of the reimbursement dollars are spent from a marketing perspective, rather than an outcome-based perspective. In other words, the insurance company is using a limited amount of money as a good-faith offer to close a patient’s file, and with membership subsidization, only promotes such reimbursement as a benefit to help sell more insurance. Utilization, compliance and outcomes are not important and, in most cases, not even required. In my opinion, this is a very short-term attitude for the wrong reasons, emphasizing marketing over outcomes.

A challenge for the future

The challenge for health clubs and fitness professionals is twofold. First and foremost, the industry needs to establish its credibility as true healthcare providers within the limits of its services. Second, as professionals, we must be responsible and accountable for what we do. People will pay out-of-pocket for fitness-type services if they are assured credibility and value for their dollars. Most people are fed up with the old healthcare system, which is basically a disease- and injury-treatment system, rather than a preventive one. Last year in this country alone, people paid more than $1 billion out-of-pocket for alternative and preventive healthcare services. There’s an old saying that puts it all in perspective: “If you always do what you always did, you will always get what you always got.”

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