The Connective IssueThe Fascia Institute & Treatment Center Journal
A weekly report from the long course of fascia medicine — this week, the map most of us never read.
No one runs a marathon without looking at the course map
Where are the hills? Where are the water stops? Where does it get hard? Health insurance has a course map too. Most of us never read it. Then it surprises us at mile 20.
This month is the best time of year to read it. Medicare open enrollment starts October 15. Marketplace enrollment on HealthCare.gov starts November 1. Most job-based plans sign you up somewhere in between. Whatever you pick now is the plan you will live with in 2027.
So this whole issue is one long guide. It is all I wish my patients knew before they walked in the door. Read it in pieces if you like. It will still be here in November.
Inside This Issue
- The words that decide your bill, and the plan types side by sideThe Long Run
- “Covered” does not mean “paid”The Wall
- Reading your EOB, fighting a denial, and the phone scriptSplit Times
- HSA, FSA, and what you can write offMile Markers
- Picking a plan if you want care at a clinic like oursPace Group
- Reimbursify: a free way to fileCourse Support
- GLP-1 drugs and a rare eye problemCourse Marshals
- CoreSalt™ — fall race seasonAid Station
On your marks.
Insurance 101: know the course before you run it
By Jacques Courseault, MD · CEO and Medical Director, The Fascia Institute & Treatment Center
The words that decide your bill
- Premium: what you pay each month just to have the plan. You pay it even if you never see a doctor.
- Deductible: what you pay each year before the plan starts to pay.
- Copay: a flat fee for a visit, like $40.
- Coinsurance: your share as a percent, like 20%, usually after the deductible.
- Out-of-pocket maximum: the most you should pay in a year for covered, in-network care. Remember that phrase. It matters later.
- Allowed amount: the price your plan decides a service is worth. It is often less than the bill.
- Network: the doctors and hospitals that signed a contract with your plan.
- Prior authorization: the plan’s approval before you get a service. Skip it, and the plan may refuse to pay.
- Explanation of Benefits (EOB): the statement your plan sends after a claim. It is not a bill. It shows what the plan paid and what you may owe.
- Plan year: the 12 months your deductible and maximum cover. For most people it resets January 1.
Plan types, side by side
| Plan type | Pays for out-of-network care? | Good fit if… |
|---|---|---|
| HMO | Most often no, except emergencies. Often needs a referral to see a specialist. | You are happy staying inside one network. |
| EPO | Most often no, except emergencies. Most need no referral. | You want a network but no referrals. |
| PPO | Yes, at a lower rate. No referral needed. | You want the freedom to see anyone. |
| POS | Yes, at a lower rate. Often needs a referral. | You want an HMO with an escape hatch. |
| HDHP | Depends on the plan underneath. A high-deductible plan can be built on any of the types above. | You are healthy, or you want an HSA. |
The type is printed on your insurance card or plan summary. If you cannot find it, call the number on the back of the card and ask.
In-network vs. out-of-network
In-network providers agreed to take your plan’s price. Out-of-network providers did not. That changes three things.
A second deductible
Many plans have a separate, higher deductible for out-of-network care, often about twice the in-network one. Money spent inside the network does not count toward it.
A second cap, or none
Those costs most often do not count toward your in-network cap. Some plans have a second cap for it. Some have no limit at all.
Balance billing
If an out-of-network provider charges more than the allowed amount, you may owe the gap. That gap most often does not count toward any cap.
The Fascia Institute is out-of-network with every insurance company
So what matters at our clinics is what your plan pays outside its network, if it pays at all. The rest of this guide is written with that in mind.
“Covered” does not mean “paid”
A shoulder surgery was approved and covered. The out-of-pocket maximum was $7,000, so the plan was to budget $7,000. The final total was $10,000.
That is a real example. How does it happen? The cap only protects covered, in-network care. Here is where the extra tends to come from.
- Someone on the team was out-of-network. The surgeon may be in-network, but the assistant surgeon, the anesthesia group, the lab, or the therapist afterward may not be.
- Things the plan does not cover. Ice machines, braces, and some slings are often excluded or paid under a separate benefit.
- The calendar. Surgery in November and rehab in January means your deductible and cap reset in the middle of rehab. You can hit two caps for one injury.
- Premiums. They never count toward the cap.
- A missed prior authorization. If one step was not approved ahead of time, the plan can refuse to pay for it.
- Drugs. Some plans track drug costs against a limit of their own.
Before any surgery or big procedure, ask
- Who will bill me? Get every name: surgeon, assistant, anesthesia, facility, lab, therapy, and equipment.
- Is each one in my network?
- Does any step need prior authorization? Has it been approved? Get the approval number.
- What will I owe? Ask the plan for its answer in writing.
- If recovery crosses into a new year, what will I owe in each year?
Why PRP and prolotherapy are not covered
We offer both, and neither is covered. Insurers call PRP (platelet-rich plasma) and prolotherapy “experimental” or “investigational” for joint problems like knee arthritis. Medicare does not cover either one. I do not know of any plan that does.
“Experimental” is a judgment about evidence, not paperwork. The research is mixed. Neither treatment is FDA-approved for knee arthritis. The FDA clears the equipment used to make PRP, not the treatment.
That is why you will always get a price from us up front. It is also why the HSA, tax, and Reimbursify sections below matter.
Read every EOB before you pay a bill
Your EOB is your receipt from the plan. Before you pay any bill for care, match it to the EOB.
- Is the date and service right? Billing mistakes are common.
- What was billed? That is the office’s price.
- What was allowed and paid? That is the plan’s price and the plan’s share.
- What do you owe? The bill should match this line. If it does not, call the billing office before you pay.
You can always ask for an itemized bill, a line-by-line list of every charge.
When the answer is “denied”
- Ask why, in writing. The denial letter has to give a reason.
- Fix simple errors first. A wrong code or a missing form causes many denials. Your doctor’s office can often send it again.
- File an appeal. Most plans let you appeal within a set time, often 180 days from the denial. Send a letter, your records, and a letter from your doctor if you can.
- Ask about an outside review. If the plan says no again, many plans let an independent reviewer look at the case.
- Watch the clock. All plans have deadlines for claims and appeals. Put them on your calendar.
The phone call script
Call the number on the back of your card. Write down the date, the name of the person you spoke to, and a reference number. Then ask:
- “Do I have out-of-network benefits for outpatient care?”
- “What is my out-of-network deductible, and how much have I met?”
- “Is there an out-of-network out-of-pocket maximum?”
- “How do you set the allowed amount for out-of-network claims?”
- “What is the deadline to submit an out-of-network claim?”
- “Does this service need prior authorization?” Give them the code if your doctor’s office can share it.
- “Is this service excluded as experimental or investigational?”
HSA, FSA, and what you can write off
A Health Savings Account (HSA) or a Flexible Spending Account (FSA) lets you pay for care with money that is not taxed. If you are in the 22% tax bracket, that works like a 22% discount.
HSA and FSA
- The IRS lets you use these accounts for care that treats a medical condition. PRP or prolotherapy for a diagnosed problem, like knee arthritis, generally qualifies. Cosmetic uses do not.
- Your account may ask for a Letter of Medical Necessity. We can write one for a fee. Ask our front desk.
- You need a high-deductible plan to open an HSA. New for 2026: bronze and catastrophic plans now count, even if they do not meet the usual rules.
- HSA money is yours to keep. It rolls over every year and moves with you if you change jobs.
- FSA money is mostly use-it-or-lose-it. Most of it is gone at the end of your plan year. Check your balance now.
Can you write it off on your taxes?
Maybe. You can deduct medical costs only above 7.5% of your adjusted gross income, and only if you itemize. Itemizing only helps if your total beats the standard deduction. For 2026, that is $16,100 if you are single and $32,200 for married couples filing together.
Income $80,000. Medical costs $9,000.
7.5% of $80,000 is $6,000. You paid $9,000 out of pocket for care. You may be able to deduct the $3,000 above that floor.
What can count:
- Care you paid for and were not paid back for
- Premiums you paid with after-tax money
- Travel to care. The 2026 IRS medical mileage rate is 20.5¢ a mile through June 30 and 23.5¢ from July 1.
- Parking and tolls
- Lodging for out-of-town care, up to a set nightly limit
Self-employed? You may be able to deduct your health premiums separately, even if you do not itemize. No double-dipping: anything paid with HSA or FSA money, or paid back by insurance, cannot also be deducted.
Keep all your receipts. Talk to a tax professional before you file. I am a doctor, not a tax advisor.
Picking a plan if you want care at a clinic like ours
Ask for each plan’s Summary of Benefits and Coverage (SBC). All plans have to give you one for free. Then check these seven things.
- Plan type. For an out-of-network clinic like ours, you need a PPO or POS plan with out-of-network benefits. An HMO or EPO most often pays nothing.
- The out-of-network deductible. It is often double the in-network one.
- The out-of-network cap. Is there one? How high is it? “No limit” is a red flag.
- How the plan sets the out-of-network allowed amount. Some pay based on a percent of Medicare rates, and that can be low.
- The exclusions list. Search the plan document for “experimental” and “investigational.”
- The math on a high-deductible plan with an HSA. If you expect a lot of cash-pay care, lower premiums plus pre-tax savings can beat a richer plan that will not cover your treatment anyway. Run the numbers both ways.
- Your whole year, not just this month. Add up premiums, the deductible, and your expected visits. The cheapest premium is not always the cheapest plan.
If you are on Medicare
Medicare open enrollment runs October 15 to December 7. There are three main pieces.
| Piece | What it does |
|---|---|
| Original Medicare (Parts A and B) | Any doctor who takes Medicare, anywhere in the country. No networks. No out-of-network benefit for clinics that do not take Medicare. |
| Medigap (supplement plans) | Helps pay Original Medicare’s share of costs. It only pays for things Medicare covers. |
| Medicare Advantage (Part C) | Private plans that replace Original Medicare. Many are HMOs with networks. PPO versions may pay out-of-network, but only for services Medicare covers. |
None of these pay for PRP or prolotherapy. If those treatments matter to you, plan to pay cash.
Your January 1 checklist
- New card? Tell each office.
- Deductible reset. Plan big care with the calendar in mind.
- New HSA or FSA amount set? Know your balance.
- Save each EOB and receipt in one folder for tax time.
- FIT patients: keep filing superbills through Reimbursify.
Superbills and Reimbursify: a free way to file
We pay for it. You take a photo.
A superbill is a detailed receipt. It lists who treated you, the date, what was done, the service and diagnosis codes, and what you paid. Your plan needs one to consider an out-of-network claim.
Filing it yourself can be a pain. So all FIT clinics now offer Reimbursify. You take a photo of your superbill and answer a few questions. It sends the claim to your insurer for you. FIT pays for Reimbursify, so it is free to you.
What it cannot do: it cannot make your plan pay for something the plan excludes. Whether you get anything back depends on your plan’s out-of-network benefits. Some services may qualify. Excluded treatments like PRP and prolotherapy usually will not. Plans also set filing deadlines, so file soon after your visit.
If you have Medicare, this most often is not an option. Original Medicare has no out-of-network benefit, and it does not cover PRP or prolotherapy.
Questions? Ask our front desk.
GLP-1 drugs and a rare eye problem
Back in Vol. IV we covered GLP-1 drugs like Ozempic, Wegovy, and Mounjaro. Here is what has changed.
Researchers have been watching a rare eye condition called NAION (non-arteritic anterior ischemic optic neuropathy). It is like a stroke in the optic nerve. It causes sudden vision loss, most often painless, in one eye, often noticed on waking.
This year, the two main U.S. eye doctor groups (NANOS and the AAO) looked at the research together. They found a possible small rise in risk, mainly with semaglutide (Ozempic, Wegovy). The overall risk stays low.
Not every study finds a link, and no one has proven the drug is the cause. Diabetes, sleep apnea, and high blood pressure all raise NAION risk on their own.
What to do
- Do not stop your medicine on your own. Talk to your prescriber.
- If you ever lose vision suddenly, even part of it, get seen the same day. Go to an eye doctor or the emergency room.
- If you have had NAION before, tell your doctor before starting a GLP-1.
- You do not need a special eye exam before starting. If you have diabetes, keep up your usual eye exams.
Fall race season and the cramp at mile 18
Built because my patients kept quitting their electrolytes— not because the science was wrong, because the powder was undrinkable
October is when a lot of you are back to long runs, long rides, or long days on your feet. Many of you also carry POTS or hypermobility, where extra salt is standard first-line advice for dizziness on standing. The advice was never the problem. Patients would try a flavored powder for two weeks and stop, because of the taste, the sweeteners, or a stomach that already does not cooperate.
So I built a taste-free capsule: sodium, magnesium and potassium, plus tyrosine, taurine, and ginger so it sits easy. No fillers, no artificial sweeteners or colors, made in an NSF-certified facility. The version you actually keep taking is the one that works.
Plainly: CoreSalt™ is our own product, formulated by Dr. Courseault — so this is a house advertisement, not a neutral comparison. Read it that way. CoreSalt™ is a dietary supplement and is not intended to diagnose, treat, cure, or prevent any disease. Sodium loading is not appropriate for everyone — talk with your physician first, particularly if you have high blood pressure, heart failure, or kidney disease.
Insurance will not run the race for you. It shows you where the hills are.
- Read your plan summary during open enrollment.
- “Covered” is not the same as “paid.” Ask who will bill you.
- Check each EOB before you pay.
- Use your HSA or FSA before the money runs out.
- Keep your receipts.
- If you are a FIT patient, file with Reimbursify. It is free.
This guide is general information, not legal, tax, or insurance advice. Every plan is different. Check your own plan documents, and ask a licensed tax professional or insurance broker about your own situation.
Know someone picking a plan this fall? Send them this issue before they sign up.