Insurance Reimbursements for Health & Wellness Service Providers in 2025

25% of insurance claims submitted by health and wellness providers to insurance companies for reimbursement are rejected on the first attempt. Just imagine it, ¼ of opportunities to stabilize your cash flow are potentially lost.

The reasons vary. For instance, a claim for a 60-minute therapy session might be denied due to a missing CPT code. The result? Hours spent correcting the error and weeks of waiting for reimbursement.

For many practices, this leads to wasted time, delayed payments, and even patient dissatisfaction. As Sachin H. Jain, President and CEO at SCAN Group & Health Plan, once said, 

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“Healthcare is overrun with companies that perform clever accounting exercises rather than change anything fundamental about the care we deliver.”

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Health & wellness service providers have to dive into routine things instead focusing on approaches to their patients. It’s far from the effectiveness we’re striving for, but it’s a reality businesses face now. And this guide aims to help you approach the challenges of insurance reimbursements in 2025 to minimize risks and focus on what matters most - your patients. 

Insurance Reimbursements and Billing: 5 Factors You Can’t Ignore

1. Patients Demand Transparency

Patients don't seek care any more. They want cohesive care, control & clarity. Questions like, “What will I owe after insurance?” demand precise answers. Without transparent systems, practices risk alienating their patients. 

One of your new patients can leave frustrated because they couldn’t get a clear estimate of their costs. 

To prevent this, health & wellness practices are forced to  invest in cost-calculating tools and train staff to explain these numbers effectively. Providing clear financial expectations strengthens trust and reduces billing disputes.

2. Value-Based Care

Insurers are increasingly tying reimbursements to patient outcomes rather than services rendered. For instance, a dietitian offering a weight-loss program might need to document tangible results such as BMI reductions or improved blood sugar levels. Without tools to track and report these metrics, practices risk losing out on reimbursements. Outcome tracking provides valuable insights to improve patient care and satisfies payers as well.

3. HSAs and FSAs: A Must for Payment Options

With over 60 million Americans relying on Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) for healthcare payments, offering these options is no longer optional. Practices that fail to accept HSA/FSA payments may lose patients to competitors. Upgrading your payment systems ensures accessibility for patients while keeping your practice competitive.

4. More Preventive Care Coverage

In 2025, U.S. health insurers are increasingly expanding coverage to include services like health and wellness coaching, and telehealth, reflecting a broader commitment to preventive care. For example, Amazon has partnered with Teladoc Health to offer chronic condition management programs, including personalized coaching for diabetes and weight management, aiming to improve health outcomes through accessible virtual care. 

Additionally, Medicare has made certain telehealth services permanent, such as mental health consultations, allowing beneficiaries to receive care from home without geographic restrictions. However, other telehealth services have reverted to pre-pandemic rules, requiring patients to be in rural areas and at approved facilities. Curious that by March 31, 2024, the HRSA identified 3,862 rural regions as Mental Health Professional Shortage Areas. Closing these gaps would require an estimated 1,682 additional mental health practitioners.

Aligning your practice with these trends by incorporating virtual wellness programs and understanding the nuances of telehealth coverage can attract more patients and enhance revenue streams. 

5. Robotic Process Automation and AI Speed Up Claims Processing

AI-powered health coaching platforms and Robotic Process Automation (RPA) can change your approach to claims workflows, covering at least 30% of tasks you have. These systems identify errors, such as mismatched codes or incomplete documentation, before submission. For example, an AI tool might flag an error in a group therapy session claim (CPT code 90853), allowing you to correct it immediately. It also speeds the search up as it's challenging to navigate and understand which claim you need exactly.

Want Insurance Reimbursements - Prove a Medical Necessity 

Insurance reimbursements for health and wellness services are closely tied to the requirement to prove medical necessity. Insurers require providers to prove that treatments are essential for diagnosing or treating a condition. For example, Medicare defines medical necessity as services reasonable and necessary for the diagnosis or treatment of an illness or injury. Without thorough documentation, claims are likely to be denied, creating bottlenecks in your health & wellness revenue cycle.

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How to Prove a Medical Necessity

Providers must ensure their documentation answers critical questions:

• What’s the Patient’s History? Include detailed symptoms, medical history, and context.
• What Tests Support the Diagnosis? Reference diagnostic results that justify treatment.
• What’s the Plan? Outline the interventions and explain why they’re needed.
• How is the Patient Progressing? Document measurable responses to care.

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If a claim doesn’t prove medical necessity, the insurer is likely to deny it, which can cause a ripple effect of problems. First, the provider won’t get reimbursed for the service, resulting in financial loss. Second, the cost might shift to the patient, which can lead to dissatisfaction, disputes, or even losing their trust. Finally, insurers might start scrutinizing the provider more closely, increasing the chances of future claims being denied and creating additional administrative headaches.

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What if Medical Necessity Denials Happened?

• Review the Denial Notice: Identify what’s missing.
• Update Documentation: Address gaps with additional evidence.
• Engage with Payers: Clarify requirements and request guidance if needed.
• Submit an Appeal: Provide a detailed letter with supporting clinical evidence, and follow up regularly to track its progress.

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Checklist: How to Approach Insurance Reimbursements for Health & Wellness Providers

1. Documentation

✅ Include the patient’s full medical history and symptoms.
✅ Reference diagnostic tests that justify the need for treatment.
✅ Clearly explain the treatment plan and why it’s necessary.
✅ Track measurable progress, such as improved lab results or health outcomes.

2. Technology and Automation

✅ Use Robotic Process Automation (RPA) or AI to identify missing codes or incomplete forms.
✅  Automate at least 30% of claims processing tasks to reduce errors and save time.
✅ Regularly update your health & wellness coach software to stay compliant with billing requirements.

3. Align with Preventive Care Trends and Value-Based Reimbursements

✅ Offer services like telemedicine, virtual nutrition counseling, or chronic care management.
✅ Track patient outcomes, such as reduced BMI or better blood sugar levels.
✅ Use outcome data to meet insurer requirements and improve care quality.

4. Cost Transparency

✅  Use cost calculators to provide patients with clear financial estimates.
✅  Train staff to communicate these estimates effectively.
✅ Accept Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) as payment options.

5. Proactive Practice Management

✅  Stay informed about changes in insurance policies and reimbursement trends.
✅  Regularly audit your billing process to catch errors early.
✅  Educate your team on best practices for claim submissions and patient communications.

The Takeaway

Does getting reimbursed for health & wellness businesses mean just flawless billing? Not really. To achieve this, you must build a system that works for your practice and your patients. It starts with nailing the basics: clear documentation, tools to reduce errors, and tracking outcomes that insurers want to see. But it’s also about meeting your patients where they are — being transparent about costs, offering flexible payment options, and showing them you value their time and trust. These steps let you focus on providing care that truly makes a difference.