Insurance Based Testing

Many insurance companies have denied coverage for saliva testing for hormones stating that it is an unproven experimental procedure which lacks scientific validation. In doing so, they ignore the hundreds of published articles which provide good evidence that saliva testing is indeed a convenient and useful method for testing hormones.

In my opinion, the insurance billing companies have denied coverage for saliva testing in hopes that the patient will choose to pay for the tests and they will not have to pay a claim. As the benefits of saliva testing on overall health continue to be demonstrated, some insurance companies have now started to cover this type of testing. These progressive companies understand that physiologic hormone balance is critical to helping prevent many disease states associated with aging. They also recognize the fact that saliva testing is much less expensive than conventional venous serum testing.

Are there any effective ways to get insurance coverage for saliva testing?
There are several methods that can be attempted, but the easiest and most successful is for the practitioner to establish a cash-based practice. Many patients understand the issues with insurance and are willing to pay for what they view as good health care. There are numerous practitioners that have changed to a cash-based practice, and the vast majority is successful and extremely satisfied with the change.

However, the other side of the picture is that the patient is still not receiving insurance coverage for a beneficial testing procedure that is saving the insurance company money in the long term. That is why, I have addressed the issue through other methods at times.

When in practice, I helped patients create a letter to use in their struggle to get saliva testing reimbursed. I inform the patient that in many cases they are dealing with the billing company hired by the insurance company to handle claims, and that the main objective of an insurance billing company is too keep down claim costs. That’s why it may be more beneficial to include copies of all correspondence to the actual insurance company and the health benefit provider at the patient’s employer.

The letter offers to supply numerous published articles that show the effectiveness and usefulness of saliva testing, and inquires if they have reviewed these articles when stating that saliva testing is unproven and experimental. At the same time, the letter asks the insurance company for studies that validate conventional venous serum testing with the administration of topical hormones, a procedure commonly covered as an acceptable way to measure hormone need.

The letter also requests that the insurance company explain why it would deny coverage for a testing procedure that the practitioner considers accurate, that the patient desires, and that is typically 1/4 to 1/3 the cost of covered conventional testing. Do they consider themselves a better judge of effectiveness and usefulness of testing than a trained medical professional?

Finally, the letter solicits that the insurance company reconsider and provide coverage immediately, so that the patient does not have to pursue other avenues of making their point. The letter also states that the patient is willing to present his/her side of the issue to the State Insurance Department Ombudsman’s Office, local and state legislators, the board of directors for the insurance company, and the local media if necessary. I suggest that the patient provide the names and addressed for all the above to indicate he/she is serious in the pursuit to obtain fair coverage.

Insurance billing companies generally do not wish to have to deal with ombudsmen, media or legislative representatives, so the letter has been successful in several cases.

What if the letter does not change the insurance companies’ stance?
If all else fails, the ordering practitioner can greatly assist the patient in getting reimbursement by providing a letter to the insurance billing company. In such a letter, the practitioner would state they have looked at the scientific studies and determined that saliva testing is indeed a valid method of measuring hormones. The practitioner should also relate their personal experience at clinical success in using saliva testing. The huge cost savings should be included as a factor in the practitioner choosing this method of testing.

Finally, a practitioner I know once wrote a letter stating that she would be using saliva testing for her patient because her training, research and clinical experience indicates it is a valid choice, and her preferred method of testing. She also declared that if the insurance company failed to cover the expense, she would also be testing the patient by conventional serum testing, so the insurance company would still be paying a claim. It would be their choice as to whether they choose to cover saliva testing or pay for the much more expensive serum testing. The practitioner also wrote she would be asking the state insurance commissioner’s office to investigate why an insurance company would unnecessarily drive up the medical costs against a practitioner’s choice if a less expensive, valid procedure is available. In this instance, coverage of saliva testing was granted within 24 hours.

What about insurance coverage for capillary blood spot testing?
There is no valid reason why dried blood spot testing should not be covered as a reimbursable procedure. Capillary blood has been validated in the literature and used for infants for over 30 years. The only issue I’ve seen is where the insurance company denied coverage based on the laboratory listed for doing the testing, one which is known for saliva testing.

Jim Paoletti, Pharmacist, FAAFM