If a procedure has not yet been proven to work, most insurance companies will not cover it. Or at least they won’t cover it at premium levels palatable to most employers.

“We constantly have to ask ourselves, what is the employer willing to pay?” said Dr. Bill Matheson at KPS Health Plans, which has 43,000 enrolled members. “We also have to balance what people will pay with the quality of care provided.”

Matheson said the long screening process for extending coverage centers around that concept. It starts with reviewing medical news services, talking to specialists and passing new coverage plan ideas through an in-house committee.

Elmer Anderson, owner of Anderson and Associates insurance consultants in Port Orchard, said insurance companies often stay one step ahead of mandates from Olympia “because it makes sound business sense,” but that they can be caught by surprise. By the beginning of 2001 the Legislature had pushed insurance companies into covering some but not all treatment variations of chiropractic work and therapeutic massage.

A rapidly progressing area of coverage is the Positron Emission Tomography, or PET scan, Anderson said.

“They are being used for diagnosis more,” Matheson said. “It used to be only for the brain but it’s used for everything now.”

They are being increasingly covered by insurance companies.

Insurance companies don’t usually worry about the specific machinery used, only what it can do and if it is up to certified standards, says Jan West at Advanced Medical Imaging. AMI has a new 1.5 Tesla magnet MRI machine. It does the same type of internal scan work that other scanners do, only more efficiently. Another tool AMI plans to bring in is a 3D-imaging ultrasound scanner.

“It acts as a second opinion on observations,” West said, “and it gives people a cuter picture of their baby.”

Before a company such as AMI buys their next $1 million body scanner, they try to make sure the majority of insurance companies will pay for what it can accomplish. That assurance means patients can come for treatment with confidence.

“Patients have a limited amount of money,” West said.

But then so do insurance carriers who leave it to experts to decide what works. As Matheson puts it: “We’re not making decisions on what’s medically correct but what it says in our contract with a business.”

Related Web sites:
AMI: www.amiradiology.com
KPS Health Plans: www.kpshealthplans.com
Washington State Insurance Commissioner: www.insurance.wa.gov

(Editor’s Note: Temple A. Stark is a freelance writer. He may be reached at writer@harbornet.com.).